Consumer Real-Time Pharmacy Benefit Check FHIR IG
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Consumer Real-Time Pharmacy Benefit Check FHIR IG, published by HL7 International / Pharmacy. This guide is not an authorized publication; it is the continuous build for version 2.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/carin-rtpbc/ and changes regularly. See the Directory of published versions

Resource Profile: RtpbcRequestClaim - Detailed Descriptions

Page standards status: Trial-use Maturity Level: 4

Definitions for the rtpbc-request-claim resource profile.

Guidance on how to interpret the contents of this table can be foundhere

0. Claim
Definition

A provider issued list of professional services and products which have been provided, or are to be provided, to a patient which is sent to an insurer for reimbursement.

ShortClaim, Pre-determination or Pre-authorization
Comments

The Claim resource fulfills three information request requirements: Claim - a request for adjudication for reimbursement for products and/or services provided; Preauthorization - a request to authorize the future provision of products and/or services including an anticipated adjudication; and, Predetermination - a request for a non-bind adjudication of possible future products and/or services.

Control0..*
Is Modifierfalse
Summaryfalse
Alternate NamesAdjudication Request, Preauthorization Request, Predetermination Request
Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty())
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty())
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. Claim.id
Definition

Unique Claim Resource Identifier assigned by the submitting patient application


The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

ShortUnique Claim Resource IdentifierLogical id of this artifact
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Control10..1
Typeidstring
Is Modifierfalse
Must Supporttrue
Summarytrue
LabelUnique Claim Resource Identifier
4. Claim.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

ShortA set of rules under which this content was created
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Control0..1
Typeuri
Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
6. Claim.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summaryfalse
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
8. Claim.identifier
Definition

A unique identifier assigned to this claim.

ShortRTPBC request identifierBusiness Identifier for claim
NoteThis is a business identifier, not a resource identifier (see discussion)
Control10..1*
TypeIdentifier
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Allows claims to be distinguished and referenced.

LabelRTPBC request identifier
Alternate NamesClaim Number
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
10. Claim.identifier.use
Definition

The purpose of this identifier.

Shortusual | official | temp | secondary | old (If known)
Comments

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Control0..1
BindingThe codes SHALL be taken from IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1
(required to http://hl7.org/fhir/ValueSet/identifier-use|4.0.1)

Identifies the purpose for this identifier, if known .

Typecode
Is Modifiertrue because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
12. Claim.identifier.value
Definition

An identifier for each RTPBC request that is assigned by and unique to the submitter


The portion of the identifier typically relevant to the user and which is unique within the context of the system.

ShortUnique RTPBC request IDThe value that is unique
Comments

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

Control10..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
LabelUnique RTPBC request ID
ExampleGeneral: 123456
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
14. Claim.status
Definition

The status of this request (active)


The status of the resource instance.

ShortRequest statusactive | cancelled | draft | entered-in-error
Comments

Value is always 'active'


This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

Control1..1
BindingThe codes SHALL be taken from FinancialResourceStatusCodeshttp://hl7.org/fhir/ValueSet/fm-status|4.0.1
(required to http://hl7.org/fhir/ValueSet/fm-status|4.0.1)

A code specifying the state of the resource instance.

Typecode
Is Modifiertrue because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

LabelRequest status
Fixed Valueactive
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
16. Claim.type
Definition

The type of service for which pricing and coverage predetermination is being requested


The category of claim, e.g. oral, pharmacy, vision, institutional, professional.

ShortRequested Service TypeCategory or discipline
Comments

Value is always 'pharmacy'


The majority of jurisdictions use: oral, pharmacy, vision, professional and institutional, or variants on those terms, as the general styles of claims. The valueset is extensible to accommodate other jurisdictional requirements.

Control1..1
BindingUnless not suitable, these codes SHALL be taken from ClaimTypeCodeshttp://hl7.org/fhir/ValueSet/claim-type
(extensible to http://hl7.org/fhir/ValueSet/claim-type)

The type or discipline-style of the claim.

TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

Claim type determine the general sets of business rules applied for information requirements and adjudication.

LabelRequested Service Type
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
18. Claim.type.coding
Definition

A reference to a code defined by a terminology system.

ShortCode defined by a terminology system
Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Control10..1*
TypeCoding
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. Claim.type.coding.system
Definition

The identification of the code system that defines the meaning of the symbol in the code.

ShortIdentity of the terminology system
Comments

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

Control10..1
Typeuri
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Need to be unambiguous about the source of the definition of the symbol.

Fixed Valuehttp://terminology.hl7.org/CodeSystem/claim-type
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
22. Claim.type.coding.code
Definition

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

ShortSymbol in syntax defined by the system
Control10..1
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Need to refer to a particular code in the system.

Fixed Valuepharmacy
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
24. Claim.type.coding.display
Definition

A representation of the meaning of the code in the system, following the rules of the system.

ShortRepresentation defined by the system
Control10..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Fixed ValuePharmacy
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
26. Claim.use
Definition

The mode of processing being requested of the payer/PBM


A code to indicate whether the nature of the request is: to request adjudication of products and services previously rendered; or requesting authorization and adjudication for provision in the future; or requesting the non-binding adjudication of the listed products and services which could be provided in the future.

ShortProcessing Modeclaim | preauthorization | predetermination
Comments

Value is always 'predetermination'

Control1..1
BindingThe codes SHALL be taken from Usehttp://hl7.org/fhir/ValueSet/claim-use|4.0.1
(required to http://hl7.org/fhir/ValueSet/claim-use|4.0.1)

The purpose of the Claim: predetermination, preauthorization, claim.

Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

This element is required to understand the nature of the request for adjudication.

LabelProcessing Mode
Fixed Valuepredetermination
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
28. Claim.patient
Definition

Limited patient information required in the consumer real-time pharmacy benefit check (RTPBC) process


The party to whom the professional services and/or products have been supplied or are being considered and for whom actual or forecast reimbursement is sought.

ShortRequest Patient InformationThe recipient of the products and services
Control1..1
TypeReference(RTPBC Patient, Patient)
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction.

LabelRequest Patient Information
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
30. Claim.patient.reference
Definition

Reference to a Patient resource


A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

ShortPatient ReferenceLiteral reference, Relative, internal or absolute URL
Comments

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

Control10..1
This element is affected by the following invariants: ref-1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
LabelPatient Reference
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
32. Claim.created
Definition

The date and time on which this RTBPC request was created


The date this resource was created.

ShortCreated DateTimeResource creation date
Comments

This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.

Control1..1
TypedateTime
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Need to record a timestamp for use by both the recipient and the issuer.

LabelCreated DateTime
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
34. Claim.provider
Definition

The patient's preferred pharmacy to be considered during creation of the response


The provider which is responsible for the claim, predetermination or preauthorization.

ShortPreferred PharmacyParty responsible for the claim
Comments

Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

Control1..1
TypeReference(RTPBC Pharmacy Organization, Practitioner, PractitionerRole, Organization)
Is Modifierfalse
Must Supporttrue
Summarytrue
LabelPreferred Pharmacy
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
36. Claim.provider.reference
Definition

Reference to an Organization resource representing the patient's preferred pharmacy


A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

ShortReference to Pharmacy OrganizationLiteral reference, Relative, internal or absolute URL
Comments

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

Control10..1
This element is affected by the following invariants: ref-1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
LabelReference to Pharmacy Organization
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
38. Claim.priority
Definition

The processing priority requested of the payer/PBM


The provider-required urgency of processing the request. Typical values include: stat, routine deferred.

ShortProcessing priorityDesired processing ugency
Comments

All requests are responded to in real-time, without differentiated priority levels. Value is always 'normal'


If a claim processor is unable to complete the processing as per the priority then they should generate and error and not process the request.

Control1..1
BindingFor example codes, see ProcessPriorityCodeshttp://hl7.org/fhir/ValueSet/process-priority
(example to http://hl7.org/fhir/ValueSet/process-priority)

The timeliness with which processing is required: stat, normal, deferred.

TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.

LabelProcessing priority
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
40. Claim.priority.coding
Definition

A reference to a code defined by a terminology system.

ShortCode defined by a terminology system
Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Control10..1*
TypeCoding
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
42. Claim.priority.coding.system
Definition

The identification of the code system that defines the meaning of the symbol in the code.

ShortIdentity of the terminology system
Comments

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

Control10..1
Typeuri
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Need to be unambiguous about the source of the definition of the symbol.

Fixed Valuehttp://terminology.hl7.org/CodeSystem/processpriority
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
44. Claim.priority.coding.code
Definition

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

ShortSymbol in syntax defined by the system
Control10..1
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Need to refer to a particular code in the system.

Fixed Valuenormal
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
46. Claim.priority.coding.display
Definition

A representation of the meaning of the code in the system, following the rules of the system.

ShortRepresentation defined by the system
Control10..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Fixed ValueNormal
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
48. Claim.prescription
Definition

Reference to the pertinent prescription information in a MedicationRequest resource.


Prescription to support the dispensing of pharmacy, device or vision products.

ShortPrescription ReferencePrescription authorizing services and products
Control10..1
TypeReference(RTPBC Medication Request, DeviceRequest, MedicationRequest, VisionPrescription)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Required to authorize the dispensing of controlled substances and devices.

LabelPrescription Reference
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
50. Claim.prescription.reference
Definition

A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

ShortLiteral reference, Relative, internal or absolute URL
Comments

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

Control10..1
This element is affected by the following invariants: ref-1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
52. Claim.careTeam
Definition

Prescriber reference


The members of the team who provided the products and services.

ShortPrescriberMembers of the care team
Comments

The careTeam represents the specific practitioner that prescribed the medication. Thus, a single careTeam element is included in the RTPBC request

Control10..1*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

The specific practitioner that prescribed the medication.


Common to identify the responsible and supporting practitioners.

LabelPrescriber
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
54. Claim.careTeam.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
56. Claim.careTeam.sequence
Definition

A number to uniquely identify care team entries.

ShortOrder of care team
Control1..1
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summaryfalse
Requirements

Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.

Fixed Value1
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
58. Claim.careTeam.provider
Definition

Prescriber of the item being submitted


Member of the team who provided the product or service.

ShortPrescriberPractitioner or organization
Control1..1
TypeReference(US Core Practitioner Profile, Practitioner, PractitionerRole, Organization)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Often a regulatory requirement to specify the responsible provider.

LabelPrescriber
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
60. Claim.careTeam.provider.reference
Definition

Reference to a Practitioner resource that represents the prescriber


A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

ShortPrescriber ReferenceLiteral reference, Relative, internal or absolute URL
Comments

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

Control10..1
This element is affected by the following invariants: ref-1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
LabelPrescriber Reference
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
62. Claim.insurance
Definition

The patient's pharmacy coverage information


Financial instruments for reimbursement for the health care products and services specified on the claim.

ShortPharmacy CoveragePatient insurance information
Comments

All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.

Control1..1*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

At least one insurer is required for a claim to be a claim.

LabelPharmacy Coverage
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
64. Claim.insurance.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
66. Claim.insurance.sequence
Definition

A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.

ShortInsurance instance identifier
Comments

Only one set of coverage is submitted in the request. Value is always '1'

Control1..1
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

To maintain order of the coverages.

Fixed Value1
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
68. Claim.insurance.focal
Definition

A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

ShortCoverage to be used for adjudication
Comments

A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.

Control1..1
Typeboolean
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

To identify which coverage in the list is being used to adjudicate this claim.

Fixed Valuetrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
70. Claim.insurance.coverage
Definition

Reference to a Coverage resource containing identification of the patient's pharmacy coverage


Reference to the insurance card level information contained in the Coverage resource. The coverage issuing insurer will use these details to locate the patient's actual coverage within the insurer's information system.

ShortPharmacy Coverage ReferenceInsurance information
Control1..1
TypeReference(RTPBC Coverage, Coverage)
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

Required to allow the adjudicator to locate the correct policy and history within their information system.

LabelPharmacy Coverage Reference
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
72. Claim.insurance.coverage.reference
Definition

Reference to a Coverage resource containing identification of the patient's pharmacy coverage


A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

ShortPharmacy Coverage ReferenceLiteral reference, Relative, internal or absolute URL
Comments

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

Control0..1
This element is affected by the following invariants: ref-1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
LabelPharmacy Coverage Reference
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
74. Claim.item
Definition

A claim line. Either a simple product or service or a 'group' of details which can each be a simple items or groups of sub-details.

ShortMax 1 item per requestProduct or service provided
Control10..1*
TypeBackboneElement
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

The items to be processed for adjudication.

LabelMax 1 item per request
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
76. Claim.item.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
78. Claim.item.sequence
Definition

A number to uniquely identify item entries.

ShortItem instance identifier
Comments

A maximum of one product is submitted per request. Value is always '1'

Control1..1
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summaryfalse
Requirements

Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.

Fixed Value1
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
80. Claim.item.careTeamSequence
Definition

A reference to the Care Team composite in this resource that reflects the prescriber


CareTeam members related to this service or product.

ShortCare Team Sequence ID ReferenceApplicable careTeam members
Comments

Populate with a reference to .careTeam.sequence.@id

Control10..1*
TypepositiveInt
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summaryfalse
Requirements

Need to identify the individuals and their roles in the provision of the product or service.

LabelCare Team Sequence ID Reference
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
82. Claim.item.productOrService
Definition

A product identifier for the prescribed medication. Either an NDC11 or an RxNorm code for a prescribable product (representing drug name, strength and dose form)


When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

ShortPrescribed ProductBilling, service, product, or drug code
Comments

The NDC11 is an 11-digit normalized format consisting of a 5-digit labeler segment, 4-digit product segment, and 2-digit package segment, with no dashes


If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

Control1..1
BindingUnless not suitable, these codes SHALL be taken from For example codes, see RTPBC Prescribable Product Code Value Sethttp://hl7.org/fhir/ValueSet/service-uscls
(extensible to http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-prescribable-product-code)

RTPBC prescribable product codes (NDC11 and RxNorm)


Allowable service and product codes.

TypeCodeableConcept
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Necessary to state what was provided or done.

LabelPrescribed Product
Alternate NamesDrug Code, Bill Code, Service Code
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
84. Claim.item.productOrService.coding
Definition

A reference to a code defined by a terminology system.

ShortCode defined by a terminology system
Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Control10..*
TypeCoding
Is Modifierfalse
Must Supporttrue
Summarytrue
Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
86. Claim.item.productOrService.coding.system
Definition

The identification of the code system that defines the meaning of the symbol in the code.

ShortIdentity of the terminology system
Comments

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

Control10..1
Typeuri
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Need to be unambiguous about the source of the definition of the symbol.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
88. Claim.item.productOrService.coding.code
Definition

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

ShortSymbol in syntax defined by the system
Control10..1
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Need to refer to a particular code in the system.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
90. Claim.item.productOrService.coding.display
Definition

The full prescribable product name, including drug name, strength and dose form. The drug name equals the brand name if the branded product is desired


A representation of the meaning of the code in the system, following the rules of the system.

ShortProduct DescriptionRepresentation defined by the system
Control10..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

LabelProduct Description
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
92. Claim.item.quantity
Definition

The number of repetitions of a service or product.

ShortPrescribed QuantityCount of products or services
Control10..1
TypeQuantity(SimpleQuantity)
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Required when the product or service code does not convey the quantity provided.

LabelPrescribed Quantity
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
94. Claim.item.quantity.value
Definition

The prescribed quantity in terms of the applicable billing unit of measure


The value of the measured amount. The value includes an implicit precision in the presentation of the value.

ShortQuantity in Billing UnitsNumerical value (with implicit precision)
Comments

The implicit precision in the value should always be honored. Monetary values have their own rules for handling precision (refer to standard accounting text books).

Control10..1
Typedecimal
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

Precision is handled implicitly in almost all cases of measurement.

LabelQuantity in Billing Units
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
96. Claim.item.quantity.comparator
Definition

Not allowed to be used in this context


How the value should be understood and represented - whether the actual value is greater or less than the stated value due to measurement issues; e.g. if the comparator is "<" , then the real value is < stated value.

Short< | <= | >= | > - how to understand the value
Control0..01
BindingThe codes SHALL be taken from QuantityComparatorhttp://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1
(required to http://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1)

How the Quantity should be understood and represented.

Typecode
Is Modifiertrue because This is labeled as "Is Modifier" because the comparator modifies the interpretation of the value significantly. If there is no comparator, then there is no modification of the value
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

Need a framework for handling measures where the value is <5ug/L or >400mg/L due to the limitations of measuring methodology.

Meaning if MissingIf there is no comparator, then there is no modification of the value
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
98. Claim.item.quantity.unit
Definition

Pharmacy metric billing unit: GM (gram), ML (milliliter) or EA (each)


A human-readable form of the unit.

ShortBilling unit of measureUnit representation
Control10..1
BindingUnless not suitable, these codes SHALL be taken from For codes, see RTPBC Billing Unit Value Set
(extensible to http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-billing-unit)

Billing quantity unit of measure

Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Must Supporttrue
Summarytrue
Requirements

There are many representations for units of measure and in many contexts, particular representations are fixed and required. I.e. mcg for micrograms.

LabelBilling unit of measure
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

Guidance on how to interpret the contents of this table can be foundhere

0. Claim
2. Claim.id
Definition

Unique Claim Resource Identifier assigned by the submitting patient application

ShortUnique Claim Resource Identifier
Control1..?
Must Supporttrue
LabelUnique Claim Resource Identifier
4. Claim.identifier
ShortRTPBC request identifier
NoteThis is a business identifier, not a resource identifier (see discussion)
Control1..1
Must Supporttrue
LabelRTPBC request identifier
6. Claim.identifier.value
Definition

An identifier for each RTPBC request that is assigned by and unique to the submitter

ShortUnique RTPBC request ID
Control1..?
Must Supporttrue
LabelUnique RTPBC request ID
8. Claim.status
Definition

The status of this request (active)

ShortRequest status
Comments

Value is always 'active'

Must Supporttrue
LabelRequest status
Fixed Valueactive
10. Claim.type
Definition

The type of service for which pricing and coverage predetermination is being requested

ShortRequested Service Type
Comments

Value is always 'pharmacy'

Must Supporttrue
LabelRequested Service Type
12. Claim.type.coding
Control1..1
Must Supporttrue
14. Claim.type.coding.system
Control1..?
Must Supporttrue
Fixed Valuehttp://terminology.hl7.org/CodeSystem/claim-type
16. Claim.type.coding.code
Control1..?
Must Supporttrue
Fixed Valuepharmacy
18. Claim.type.coding.display
Control1..?
Must Supporttrue
Fixed ValuePharmacy
20. Claim.use
Definition

The mode of processing being requested of the payer/PBM

ShortProcessing Mode
Comments

Value is always 'predetermination'

Must Supporttrue
LabelProcessing Mode
Fixed Valuepredetermination
22. Claim.patient
Definition

Limited patient information required in the consumer real-time pharmacy benefit check (RTPBC) process

ShortRequest Patient Information
TypeReference(RTPBC Patient)
Must Supporttrue
LabelRequest Patient Information
24. Claim.patient.reference
Definition

Reference to a Patient resource

ShortPatient Reference
Control1..?
Must Supporttrue
LabelPatient Reference
26. Claim.created
Definition

The date and time on which this RTBPC request was created

ShortCreated DateTime
Must Supporttrue
LabelCreated DateTime
28. Claim.provider
Definition

The patient's preferred pharmacy to be considered during creation of the response

ShortPreferred Pharmacy
TypeReference(RTPBC Pharmacy Organization)
Must Supporttrue
LabelPreferred Pharmacy
30. Claim.provider.reference
Definition

Reference to an Organization resource representing the patient's preferred pharmacy

ShortReference to Pharmacy Organization
Control1..?
Must Supporttrue
LabelReference to Pharmacy Organization
32. Claim.priority
Definition

The processing priority requested of the payer/PBM

ShortProcessing priority
Comments

All requests are responded to in real-time, without differentiated priority levels. Value is always 'normal'

Must Supporttrue
LabelProcessing priority
34. Claim.priority.coding
Control1..1
Must Supporttrue
36. Claim.priority.coding.system
Control1..?
Must Supporttrue
Fixed Valuehttp://terminology.hl7.org/CodeSystem/processpriority
38. Claim.priority.coding.code
Control1..?
Must Supporttrue
Fixed Valuenormal
40. Claim.priority.coding.display
Control1..?
Must Supporttrue
Fixed ValueNormal
42. Claim.prescription
Definition

Reference to the pertinent prescription information in a MedicationRequest resource.

ShortPrescription Reference
Control1..?
TypeReference(RTPBC Medication Request)
Must Supporttrue
LabelPrescription Reference
44. Claim.prescription.reference
Control1..?
Must Supporttrue
46. Claim.careTeam
Definition

Prescriber reference

ShortPrescriber
Comments

The careTeam represents the specific practitioner that prescribed the medication. Thus, a single careTeam element is included in the RTPBC request

Control1..1
Must Supporttrue
Requirements

The specific practitioner that prescribed the medication.

LabelPrescriber
48. Claim.careTeam.sequence
Must Supporttrue
Fixed Value1
50. Claim.careTeam.provider
Definition

Prescriber of the item being submitted

ShortPrescriber
TypeReference(US Core Practitioner Profile)
Must Supporttrue
LabelPrescriber
52. Claim.careTeam.provider.reference
Definition

Reference to a Practitioner resource that represents the prescriber

ShortPrescriber Reference
Control1..?
Must Supporttrue
LabelPrescriber Reference
54. Claim.insurance
Definition

The patient's pharmacy coverage information

ShortPharmacy Coverage
Control0..1
Must Supporttrue
LabelPharmacy Coverage
56. Claim.insurance.sequence
Comments

Only one set of coverage is submitted in the request. Value is always '1'

Must Supporttrue
Fixed Value1
58. Claim.insurance.focal
Must Supporttrue
Fixed Valuetrue
60. Claim.insurance.coverage
Definition

Reference to a Coverage resource containing identification of the patient's pharmacy coverage

ShortPharmacy Coverage Reference
TypeReference(RTPBC Coverage)
Must Supporttrue
LabelPharmacy Coverage Reference
62. Claim.insurance.coverage.reference
Definition

Reference to a Coverage resource containing identification of the patient's pharmacy coverage

ShortPharmacy Coverage Reference
Must Supporttrue
LabelPharmacy Coverage Reference
64. Claim.item
ShortMax 1 item per request
Control1..1
Must Supporttrue
LabelMax 1 item per request
66. Claim.item.sequence
Comments

A maximum of one product is submitted per request. Value is always '1'

Must Supporttrue
Fixed Value1
68. Claim.item.careTeamSequence
Definition

A reference to the Care Team composite in this resource that reflects the prescriber

ShortCare Team Sequence ID Reference
Comments

Populate with a reference to .careTeam.sequence.@id

Control1..1
Must Supporttrue
LabelCare Team Sequence ID Reference
70. Claim.item.productOrService
Definition

A product identifier for the prescribed medication. Either an NDC11 or an RxNorm code for a prescribable product (representing drug name, strength and dose form)

ShortPrescribed Product
Comments

The NDC11 is an 11-digit normalized format consisting of a 5-digit labeler segment, 4-digit product segment, and 2-digit package segment, with no dashes

BindingUnless not suitable, these codes SHALL be taken from RTPBC Prescribable Product Code Value Set
(extensible to http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-prescribable-product-code)

RTPBC prescribable product codes (NDC11 and RxNorm)

Must Supporttrue
LabelPrescribed Product
72. Claim.item.productOrService.coding
Control1..?
Must Supporttrue
74. Claim.item.productOrService.coding.system
Control1..?
Must Supporttrue
76. Claim.item.productOrService.coding.code
Control1..?
Must Supporttrue
78. Claim.item.productOrService.coding.display
Definition

The full prescribable product name, including drug name, strength and dose form. The drug name equals the brand name if the branded product is desired

ShortProduct Description
Control1..?
Must Supporttrue
LabelProduct Description
80. Claim.item.quantity
ShortPrescribed Quantity
Control1..?
Must Supporttrue
LabelPrescribed Quantity
82. Claim.item.quantity.value
Definition

The prescribed quantity in terms of the applicable billing unit of measure

ShortQuantity in Billing Units
Control1..?
Must Supporttrue
LabelQuantity in Billing Units
84. Claim.item.quantity.unit
Definition

Pharmacy metric billing unit: GM (gram), ML (milliliter) or EA (each)

ShortBilling unit of measure
Control1..?
BindingUnless not suitable, these codes SHALL be taken from RTPBC Billing Unit Value Set
(extensible to http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-billing-unit)

Billing quantity unit of measure

Must Supporttrue
LabelBilling unit of measure

Guidance on how to interpret the contents of this table can be foundhere

0. Claim
Definition

A provider issued list of professional services and products which have been provided, or are to be provided, to a patient which is sent to an insurer for reimbursement.

ShortClaim, Pre-determination or Pre-authorization
Comments

The Claim resource fulfills three information request requirements: Claim - a request for adjudication for reimbursement for products and/or services provided; Preauthorization - a request to authorize the future provision of products and/or services including an anticipated adjudication; and, Predetermination - a request for a non-bind adjudication of possible future products and/or services.

Control0..*
Is Modifierfalse
Summaryfalse
Alternate NamesAdjudication Request, Preauthorization Request, Predetermination Request
Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource (contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty())
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated (contained.meta.versionId.empty() and contained.meta.lastUpdated.empty())
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. Claim.id
Definition

Unique Claim Resource Identifier assigned by the submitting patient application

ShortUnique Claim Resource Identifier
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Control1..1
Typeid
Is Modifierfalse
Must Supporttrue
Summarytrue
LabelUnique Claim Resource Identifier
4. Claim.meta
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

ShortMetadata about the resource
Control0..1
TypeMeta
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
6. Claim.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

ShortA set of rules under which this content was created
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Control0..1
Typeuri
Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
8. Claim.language
Definition

The base language in which the resource is written.

ShortLanguage of the resource content
Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Control0..1
BindingThe codes SHOULD be taken from CommonLanguages
(preferred to http://hl7.org/fhir/ValueSet/languages)

A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
10. Claim.text
Definition

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

ShortText summary of the resource, for human interpretation
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

Control0..1
TypeNarrative
Is Modifierfalse
Summaryfalse
Alternate Namesnarrative, html, xhtml, display
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
12. Claim.contained
Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

ShortContained, inline Resources
Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

Control0..*
TypeResource
Is Modifierfalse
Summaryfalse
Alternate Namesinline resources, anonymous resources, contained resources
14. Claim.extension
Definition

May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
16. Claim.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summaryfalse
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
18. Claim.identifier
Definition

A unique identifier assigned to this claim.

ShortRTPBC request identifier
NoteThis is a business identifier, not a resource identifier (see discussion)
Control1..1
TypeIdentifier
Is Modifierfalse
Must Supporttrue
Summaryfalse
Requirements

Allows claims to be distinguished and referenced.

LabelRTPBC request identifier
Alternate NamesClaim Number
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
20. Claim.identifier.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
22. Claim.identifier.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
SlicingThis element introduces a set of slices on Claim.identifier.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • value @ url
  • 24. Claim.identifier.use
    Definition

    The purpose of this identifier.

    Shortusual | official | temp | secondary | old (If known)
    Comments

    Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

    Control0..1
    BindingThe codes SHALL be taken from IdentifierUse
    (required to http://hl7.org/fhir/ValueSet/identifier-use|4.0.1)

    Identifies the purpose for this identifier, if known .

    Typecode
    Is Modifiertrue because This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summarytrue
    Requirements

    Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    26. Claim.identifier.type
    Definition

    A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

    ShortDescription of identifier
    Comments

    This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

    Control0..1
    BindingUnless not suitable, these codes SHALL be taken from Identifier Type Codes
    (extensible to http://hl7.org/fhir/ValueSet/identifier-type)

    A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

    TypeCodeableConcept
    Is Modifierfalse
    Summarytrue
    Requirements

    Allows users to make use of identifiers when the identifier system is not known.

    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    28. Claim.identifier.system
    Definition

    Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

    ShortThe namespace for the identifier value
    Comments

    Identifier.system is always case sensitive.

    Control0..1
    Typeuri
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summarytrue
    Requirements

    There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

    ExampleGeneral: http://www.acme.com/identifiers/patient
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    30. Claim.identifier.value
    Definition

    An identifier for each RTPBC request that is assigned by and unique to the submitter

    ShortUnique RTPBC request ID
    Comments

    If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

    Control1..1
    Typestring
    Is Modifierfalse
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summarytrue
    LabelUnique RTPBC request ID
    ExampleGeneral: 123456
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    32. Claim.identifier.period
    Definition

    Time period during which identifier is/was valid for use.

    ShortTime period when id is/was valid for use
    Control0..1
    TypePeriod
    Is Modifierfalse
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    34. Claim.identifier.assigner
    Definition

    Organization that issued/manages the identifier.

    ShortOrganization that issued id (may be just text)
    Comments

    The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.

    Control0..1
    TypeReference(Organization)
    Is Modifierfalse
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    36. Claim.status
    Definition

    The status of this request (active)

    ShortRequest status
    Comments

    Value is always 'active'

    Control1..1
    BindingThe codes SHALL be taken from FinancialResourceStatusCodes
    (required to http://hl7.org/fhir/ValueSet/fm-status|4.0.1)

    A code specifying the state of the resource instance.

    Typecode
    Is Modifiertrue because This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Must Supporttrue
    Summarytrue
    Requirements

    Need to track the status of the resource as 'draft' resources may undergo further edits while 'active' resources are immutable and may only have their status changed to 'cancelled'.

    LabelRequest status
    Fixed Valueactive
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    38. Claim.type
    Definition

    The type of service for which pricing and coverage predetermination is being requested

    ShortRequested Service Type
    Comments

    Value is always 'pharmacy'

    Control1..1
    BindingUnless not suitable, these codes SHALL be taken from ClaimTypeCodes
    (extensible to http://hl7.org/fhir/ValueSet/claim-type)

    The type or discipline-style of the claim.

    TypeCodeableConcept
    Is Modifierfalse
    Must Supporttrue
    Summarytrue
    Requirements

    Claim type determine the general sets of business rules applied for information requirements and adjudication.

    LabelRequested Service Type
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    40. Claim.type.id
    Definition

    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

    ShortUnique id for inter-element referencing
    Control0..1
    Typestring
    Is Modifierfalse
    XML FormatIn the XML format, this property is represented as an attribute.
    Summaryfalse
    42. Claim.type.extension
    Definition

    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

    ShortAdditional content defined by implementations
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    SlicingThis element introduces a set of slices on Claim.type.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • value @ url
    • 44. Claim.type.coding
      Definition

      A reference to a code defined by a terminology system.

      ShortCode defined by a terminology system
      Comments

      Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

      Control1..1
      TypeCoding
      Is Modifierfalse
      Must Supporttrue
      Summarytrue
      Requirements

      Allows for alternative encodings within a code system, and translations to other code systems.

      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      46. Claim.type.coding.id
      Definition

      Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

      ShortUnique id for inter-element referencing
      Control0..1
      Typestring
      Is Modifierfalse
      XML FormatIn the XML format, this property is represented as an attribute.
      Summaryfalse
      48. Claim.type.coding.extension
      Definition

      May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

      ShortAdditional content defined by implementations
      Comments

      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

      Control0..*
      TypeExtension
      Is Modifierfalse
      Summaryfalse
      Alternate Namesextensions, user content
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      SlicingThis element introduces a set of slices on Claim.type.coding.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
      • value @ url
      • 50. Claim.type.coding.system
        Definition

        The identification of the code system that defines the meaning of the symbol in the code.

        ShortIdentity of the terminology system
        Comments

        The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

        Control1..1
        Typeuri
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Must Supporttrue
        Summarytrue
        Requirements

        Need to be unambiguous about the source of the definition of the symbol.

        Fixed Valuehttp://terminology.hl7.org/CodeSystem/claim-type
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        52. Claim.type.coding.version
        Definition

        The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

        ShortVersion of the system - if relevant
        Comments

        Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

        NoteThis is a business version Id, not a resource version Id (see discussion)
        Control0..1
        Typestring
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Summarytrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        54. Claim.type.coding.code
        Definition

        A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

        ShortSymbol in syntax defined by the system
        Control1..1
        Typecode
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Must Supporttrue
        Summarytrue
        Requirements

        Need to refer to a particular code in the system.

        Fixed Valuepharmacy
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        56. Claim.type.coding.display
        Definition

        A representation of the meaning of the code in the system, following the rules of the system.

        ShortRepresentation defined by the system
        Control1..1
        Typestring
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Must Supporttrue
        Summarytrue
        Requirements

        Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

        Fixed ValuePharmacy
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        58. Claim.type.coding.userSelected
        Definition

        Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).

        ShortIf this coding was chosen directly by the user
        Comments

        Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

        Control0..1
        Typeboolean
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Summarytrue
        Requirements

        This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        60. Claim.type.text
        Definition

        A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

        ShortPlain text representation of the concept
        Comments

        Very often the text is the same as a displayName of one of the codings.

        Control0..1
        Typestring
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Summarytrue
        Requirements

        The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        62. Claim.subType
        Definition

        A finer grained suite of claim type codes which may convey additional information such as Inpatient vs Outpatient and/or a specialty service.

        ShortMore granular claim type
        Comments

        This may contain the local bill type codes, for example the US UB-04 bill type code or the CMS bill type.

        Control0..1
        BindingFor example codes, see ExampleClaimSubTypeCodes
        (example to http://hl7.org/fhir/ValueSet/claim-subtype)

        A more granular claim typecode.

        TypeCodeableConcept
        Is Modifierfalse
        Summaryfalse
        Requirements

        Some jurisdictions need a finer grained claim type for routing and adjudication.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        64. Claim.use
        Definition

        The mode of processing being requested of the payer/PBM

        ShortProcessing Mode
        Comments

        Value is always 'predetermination'

        Control1..1
        BindingThe codes SHALL be taken from Use
        (required to http://hl7.org/fhir/ValueSet/claim-use|4.0.1)

        The purpose of the Claim: predetermination, preauthorization, claim.

        Typecode
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Must Supporttrue
        Summarytrue
        Requirements

        This element is required to understand the nature of the request for adjudication.

        LabelProcessing Mode
        Fixed Valuepredetermination
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        66. Claim.patient
        Definition

        Limited patient information required in the consumer real-time pharmacy benefit check (RTPBC) process

        ShortRequest Patient Information
        Control1..1
        TypeReference(RTPBC Patient)
        Is Modifierfalse
        Must Supporttrue
        Summarytrue
        Requirements

        The patient must be supplied to the insurer so that confirmation of coverage and service history may be considered as part of the authorization and/or adjudiction.

        LabelRequest Patient Information
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        68. Claim.patient.id
        Definition

        Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

        ShortUnique id for inter-element referencing
        Control0..1
        Typestring
        Is Modifierfalse
        XML FormatIn the XML format, this property is represented as an attribute.
        Summaryfalse
        70. Claim.patient.extension
        Definition

        May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

        ShortAdditional content defined by implementations
        Comments

        There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

        Control0..*
        TypeExtension
        Is Modifierfalse
        Summaryfalse
        Alternate Namesextensions, user content
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        SlicingThis element introduces a set of slices on Claim.patient.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
        • value @ url
        • 72. Claim.patient.reference
          Definition

          Reference to a Patient resource

          ShortPatient Reference
          Comments

          Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

          Control1..1
          This element is affected by the following invariants: ref-1
          Typestring
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Must Supporttrue
          Summarytrue
          LabelPatient Reference
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          74. Claim.patient.type
          Definition

          The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

          The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).

          ShortType the reference refers to (e.g. "Patient")
          Comments

          This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.

          Control0..1
          BindingUnless not suitable, these codes SHALL be taken from ResourceType
          (extensible to http://hl7.org/fhir/ValueSet/resource-types)

          Aa resource (or, for logical models, the URI of the logical model).

          Typeuri
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Summarytrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          76. Claim.patient.identifier
          Definition

          An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

          ShortLogical reference, when literal reference is not known
          Comments

          When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

          When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

          Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

          Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

          NoteThis is a business identifier, not a resource identifier (see discussion)
          Control0..1
          TypeIdentifier
          Is Modifierfalse
          Summarytrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          78. Claim.patient.display
          Definition

          Plain text narrative that identifies the resource in addition to the resource reference.

          ShortText alternative for the resource
          Comments

          This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

          Control0..1
          Typestring
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Summarytrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          80. Claim.billablePeriod
          Definition

          The period for which charges are being submitted.

          ShortRelevant time frame for the claim
          Comments

          Typically this would be today or in the past for a claim, and today or in the future for preauthorizations and predeterminations. Typically line item dates of service should fall within the billing period if one is specified.

          Control0..1
          TypePeriod
          Is Modifierfalse
          Summarytrue
          Requirements

          A number jurisdictions required the submission of the billing period when submitting claims for example for hospital stays or long-term care.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          82. Claim.created
          Definition

          The date and time on which this RTBPC request was created

          ShortCreated DateTime
          Comments

          This field is independent of the date of creation of the resource as it may reflect the creation date of a source document prior to digitization. Typically for claims all services must be completed as of this date.

          Control1..1
          TypedateTime
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Must Supporttrue
          Summarytrue
          Requirements

          Need to record a timestamp for use by both the recipient and the issuer.

          LabelCreated DateTime
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          84. Claim.enterer
          Definition

          Individual who created the claim, predetermination or preauthorization.

          ShortAuthor of the claim
          Control0..1
          TypeReference(Practitioner, PractitionerRole)
          Is Modifierfalse
          Summaryfalse
          Requirements

          Some jurisdictions require the contact information for personnel completing claims.

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          86. Claim.insurer
          Definition

          The Insurer who is target of the request.

          ShortTarget
          Control0..1
          TypeReference(Organization)
          Is Modifierfalse
          Summarytrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          88. Claim.provider
          Definition

          The patient's preferred pharmacy to be considered during creation of the response

          ShortPreferred Pharmacy
          Comments

          Typically this field would be 1..1 where this party is responsible for the claim but not necessarily professionally responsible for the provision of the individual products and services listed below.

          Control1..1
          TypeReference(RTPBC Pharmacy Organization)
          Is Modifierfalse
          Must Supporttrue
          Summarytrue
          LabelPreferred Pharmacy
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          90. Claim.provider.id
          Definition

          Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

          ShortUnique id for inter-element referencing
          Control0..1
          Typestring
          Is Modifierfalse
          XML FormatIn the XML format, this property is represented as an attribute.
          Summaryfalse
          92. Claim.provider.extension
          Definition

          May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

          ShortAdditional content defined by implementations
          Comments

          There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

          Control0..*
          TypeExtension
          Is Modifierfalse
          Summaryfalse
          Alternate Namesextensions, user content
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          SlicingThis element introduces a set of slices on Claim.provider.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
          • value @ url
          • 94. Claim.provider.reference
            Definition

            Reference to an Organization resource representing the patient's preferred pharmacy

            ShortReference to Pharmacy Organization
            Comments

            Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

            Control1..1
            This element is affected by the following invariants: ref-1
            Typestring
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Must Supporttrue
            Summarytrue
            LabelReference to Pharmacy Organization
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            96. Claim.provider.type
            Definition

            The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

            The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).

            ShortType the reference refers to (e.g. "Patient")
            Comments

            This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.

            Control0..1
            BindingUnless not suitable, these codes SHALL be taken from ResourceType
            (extensible to http://hl7.org/fhir/ValueSet/resource-types)

            Aa resource (or, for logical models, the URI of the logical model).

            Typeuri
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Summarytrue
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            98. Claim.provider.identifier
            Definition

            An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

            ShortLogical reference, when literal reference is not known
            Comments

            When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

            When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

            Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

            Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

            NoteThis is a business identifier, not a resource identifier (see discussion)
            Control0..1
            TypeIdentifier
            Is Modifierfalse
            Summarytrue
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            100. Claim.provider.display
            Definition

            Plain text narrative that identifies the resource in addition to the resource reference.

            ShortText alternative for the resource
            Comments

            This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

            Control0..1
            Typestring
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Summarytrue
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            102. Claim.priority
            Definition

            The processing priority requested of the payer/PBM

            ShortProcessing priority
            Comments

            All requests are responded to in real-time, without differentiated priority levels. Value is always 'normal'

            Control1..1
            BindingFor example codes, see ProcessPriorityCodes
            (example to http://hl7.org/fhir/ValueSet/process-priority)

            The timeliness with which processing is required: stat, normal, deferred.

            TypeCodeableConcept
            Is Modifierfalse
            Must Supporttrue
            Summarytrue
            Requirements

            The provider may need to indicate their processing requirements so that the processor can indicate if they are unable to comply.

            LabelProcessing priority
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            104. Claim.priority.id
            Definition

            Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

            ShortUnique id for inter-element referencing
            Control0..1
            Typestring
            Is Modifierfalse
            XML FormatIn the XML format, this property is represented as an attribute.
            Summaryfalse
            106. Claim.priority.extension
            Definition

            May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

            ShortAdditional content defined by implementations
            Comments

            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

            Control0..*
            TypeExtension
            Is Modifierfalse
            Summaryfalse
            Alternate Namesextensions, user content
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            SlicingThis element introduces a set of slices on Claim.priority.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
            • value @ url
            • 108. Claim.priority.coding
              Definition

              A reference to a code defined by a terminology system.

              ShortCode defined by a terminology system
              Comments

              Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

              Control1..1
              TypeCoding
              Is Modifierfalse
              Must Supporttrue
              Summarytrue
              Requirements

              Allows for alternative encodings within a code system, and translations to other code systems.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              110. Claim.priority.coding.id
              Definition

              Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

              ShortUnique id for inter-element referencing
              Control0..1
              Typestring
              Is Modifierfalse
              XML FormatIn the XML format, this property is represented as an attribute.
              Summaryfalse
              112. Claim.priority.coding.extension
              Definition

              May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

              ShortAdditional content defined by implementations
              Comments

              There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

              Control0..*
              TypeExtension
              Is Modifierfalse
              Summaryfalse
              Alternate Namesextensions, user content
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
              SlicingThis element introduces a set of slices on Claim.priority.coding.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
              • value @ url
              • 114. Claim.priority.coding.system
                Definition

                The identification of the code system that defines the meaning of the symbol in the code.

                ShortIdentity of the terminology system
                Comments

                The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

                Control1..1
                Typeuri
                Is Modifierfalse
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                Must Supporttrue
                Summarytrue
                Requirements

                Need to be unambiguous about the source of the definition of the symbol.

                Fixed Valuehttp://terminology.hl7.org/CodeSystem/processpriority
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                116. Claim.priority.coding.version
                Definition

                The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

                ShortVersion of the system - if relevant
                Comments

                Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

                NoteThis is a business version Id, not a resource version Id (see discussion)
                Control0..1
                Typestring
                Is Modifierfalse
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                Summarytrue
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                118. Claim.priority.coding.code
                Definition

                A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

                ShortSymbol in syntax defined by the system
                Control1..1
                Typecode
                Is Modifierfalse
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                Must Supporttrue
                Summarytrue
                Requirements

                Need to refer to a particular code in the system.

                Fixed Valuenormal
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                120. Claim.priority.coding.display
                Definition

                A representation of the meaning of the code in the system, following the rules of the system.

                ShortRepresentation defined by the system
                Control1..1
                Typestring
                Is Modifierfalse
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                Must Supporttrue
                Summarytrue
                Requirements

                Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

                Fixed ValueNormal
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                122. Claim.priority.coding.userSelected
                Definition

                Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).

                ShortIf this coding was chosen directly by the user
                Comments

                Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

                Control0..1
                Typeboolean
                Is Modifierfalse
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                Summarytrue
                Requirements

                This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                124. Claim.priority.text
                Definition

                A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

                ShortPlain text representation of the concept
                Comments

                Very often the text is the same as a displayName of one of the codings.

                Control0..1
                Typestring
                Is Modifierfalse
                Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                Summarytrue
                Requirements

                The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                126. Claim.fundsReserve
                Definition

                A code to indicate whether and for whom funds are to be reserved for future claims.

                ShortFor whom to reserve funds
                Comments

                This field is only used for preauthorizations.

                Control0..1
                BindingFor example codes, see Funds Reservation Codes
                (example to http://hl7.org/fhir/ValueSet/fundsreserve)

                For whom funds are to be reserved: (Patient, Provider, None).

                TypeCodeableConcept
                Is Modifierfalse
                Summaryfalse
                Requirements

                In the case of a Pre-Determination/Pre-Authorization the provider may request that funds in the amount of the expected Benefit be reserved ('Patient' or 'Provider') to pay for the Benefits determined on the subsequent claim(s). 'None' explicitly indicates no funds reserving is requested.

                Alternate NamesFund pre-allocation
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                128. Claim.related
                Definition

                Other claims which are related to this claim such as prior submissions or claims for related services or for the same event.

                ShortPrior or corollary claims
                Comments

                For example, for the original treatment and follow-up exams.

                Control0..*
                TypeBackboneElement
                Is Modifierfalse
                Summaryfalse
                Requirements

                For workplace or other accidents it is common to relate separate claims arising from the same event.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                130. Claim.related.id
                Definition

                Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                ShortUnique id for inter-element referencing
                Control0..1
                Typestring
                Is Modifierfalse
                XML FormatIn the XML format, this property is represented as an attribute.
                Summaryfalse
                132. Claim.related.extension
                Definition

                May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                ShortAdditional content defined by implementations
                Comments

                There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                Control0..*
                TypeExtension
                Is Modifierfalse
                Summaryfalse
                Alternate Namesextensions, user content
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                134. Claim.related.modifierExtension
                Definition

                May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                ShortExtensions that cannot be ignored even if unrecognized
                Comments

                There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                Control0..*
                TypeExtension
                Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                Summarytrue
                Requirements

                Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                Alternate Namesextensions, user content, modifiers
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                136. Claim.related.claim
                Definition

                Reference to a related claim.

                ShortReference to the related claim
                Control0..1
                TypeReference(Claim)
                Is Modifierfalse
                Summaryfalse
                Requirements

                For workplace or other accidents it is common to relate separate claims arising from the same event.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                138. Claim.related.relationship
                Definition

                A code to convey how the claims are related.

                ShortHow the reference claim is related
                Comments

                For example, prior claim or umbrella.

                Control0..1
                BindingFor example codes, see ExampleRelatedClaimRelationshipCodes
                (example to http://hl7.org/fhir/ValueSet/related-claim-relationship)

                Relationship of this claim to a related Claim.

                TypeCodeableConcept
                Is Modifierfalse
                Summaryfalse
                Requirements

                Some insurers need a declaration of the type of relationship.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                140. Claim.related.reference
                Definition

                An alternate organizational reference to the case or file to which this particular claim pertains.

                ShortFile or case reference
                Comments

                For example, Property/Casualty insurer claim # or Workers Compensation case # .

                Control0..1
                TypeIdentifier
                Is Modifierfalse
                Summaryfalse
                Requirements

                In cases where an event-triggered claim is being submitted to an insurer which requires a reference number to be specified on all exchanges.

                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                142. Claim.prescription
                Definition

                Reference to the pertinent prescription information in a MedicationRequest resource.

                ShortPrescription Reference
                Control1..1
                TypeReference(RTPBC Medication Request)
                Is Modifierfalse
                Must Supporttrue
                Summaryfalse
                Requirements

                Required to authorize the dispensing of controlled substances and devices.

                LabelPrescription Reference
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                144. Claim.prescription.id
                Definition

                Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                ShortUnique id for inter-element referencing
                Control0..1
                Typestring
                Is Modifierfalse
                XML FormatIn the XML format, this property is represented as an attribute.
                Summaryfalse
                146. Claim.prescription.extension
                Definition

                May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                ShortAdditional content defined by implementations
                Comments

                There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                Control0..*
                TypeExtension
                Is Modifierfalse
                Summaryfalse
                Alternate Namesextensions, user content
                Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                SlicingThis element introduces a set of slices on Claim.prescription.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                • value @ url
                • 148. Claim.prescription.reference
                  Definition

                  A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

                  ShortLiteral reference, Relative, internal or absolute URL
                  Comments

                  Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

                  Control1..1
                  This element is affected by the following invariants: ref-1
                  Typestring
                  Is Modifierfalse
                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                  Must Supporttrue
                  Summarytrue
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  150. Claim.prescription.type
                  Definition

                  The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

                  The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).

                  ShortType the reference refers to (e.g. "Patient")
                  Comments

                  This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.

                  Control0..1
                  BindingUnless not suitable, these codes SHALL be taken from ResourceType
                  (extensible to http://hl7.org/fhir/ValueSet/resource-types)

                  Aa resource (or, for logical models, the URI of the logical model).

                  Typeuri
                  Is Modifierfalse
                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                  Summarytrue
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  152. Claim.prescription.identifier
                  Definition

                  An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

                  ShortLogical reference, when literal reference is not known
                  Comments

                  When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

                  When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

                  Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

                  Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

                  NoteThis is a business identifier, not a resource identifier (see discussion)
                  Control0..1
                  TypeIdentifier
                  Is Modifierfalse
                  Summarytrue
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  154. Claim.prescription.display
                  Definition

                  Plain text narrative that identifies the resource in addition to the resource reference.

                  ShortText alternative for the resource
                  Comments

                  This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

                  Control0..1
                  Typestring
                  Is Modifierfalse
                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                  Summarytrue
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  156. Claim.originalPrescription
                  Definition

                  Original prescription which has been superseded by this prescription to support the dispensing of pharmacy services, medications or products.

                  ShortOriginal prescription if superseded by fulfiller
                  Comments

                  For example, a physician may prescribe a medication which the pharmacy determines is contraindicated, or for which the patient has an intolerance, and therefore issues a new prescription for an alternate medication which has the same therapeutic intent. The prescription from the pharmacy becomes the 'prescription' and that from the physician becomes the 'original prescription'.

                  Control0..1
                  TypeReference(DeviceRequest, MedicationRequest, VisionPrescription)
                  Is Modifierfalse
                  Summaryfalse
                  Requirements

                  Often required when a fulfiller varies what is fulfilled from that authorized on the original prescription.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  158. Claim.payee
                  Definition

                  The party to be reimbursed for cost of the products and services according to the terms of the policy.

                  ShortRecipient of benefits payable
                  Comments

                  Often providers agree to receive the benefits payable to reduce the near-term costs to the patient. The insurer may decline to pay the provider and choose to pay the subscriber instead.

                  Control0..1
                  TypeBackboneElement
                  Is Modifierfalse
                  Summaryfalse
                  Requirements

                  The provider needs to specify who they wish to be reimbursed and the claims processor needs express who they will reimburse.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  160. Claim.payee.id
                  Definition

                  Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                  ShortUnique id for inter-element referencing
                  Control0..1
                  Typestring
                  Is Modifierfalse
                  XML FormatIn the XML format, this property is represented as an attribute.
                  Summaryfalse
                  162. Claim.payee.extension
                  Definition

                  May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                  ShortAdditional content defined by implementations
                  Comments

                  There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                  Control0..*
                  TypeExtension
                  Is Modifierfalse
                  Summaryfalse
                  Alternate Namesextensions, user content
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                  164. Claim.payee.modifierExtension
                  Definition

                  May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                  Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                  ShortExtensions that cannot be ignored even if unrecognized
                  Comments

                  There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                  Control0..*
                  TypeExtension
                  Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                  Summarytrue
                  Requirements

                  Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                  Alternate Namesextensions, user content, modifiers
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                  166. Claim.payee.type
                  Definition

                  Type of Party to be reimbursed: subscriber, provider, other.

                  ShortCategory of recipient
                  Control1..1
                  BindingFor example codes, see Claim Payee Type Codes
                  (example to http://hl7.org/fhir/ValueSet/payeetype)

                  A code for the party to be reimbursed.

                  TypeCodeableConcept
                  Is Modifierfalse
                  Summaryfalse
                  Requirements

                  Need to know who should receive payment with the most common situations being the Provider (assignment of benefits) or the Subscriber.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  168. Claim.payee.party
                  Definition

                  Reference to the individual or organization to whom any payment will be made.

                  ShortRecipient reference
                  Comments

                  Not required if the payee is 'subscriber' or 'provider'.

                  Control0..1
                  TypeReference(Practitioner, PractitionerRole, Organization, Patient, RelatedPerson)
                  Is Modifierfalse
                  Summaryfalse
                  Requirements

                  Need to provide demographics if the payee is not 'subscriber' nor 'provider'.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  170. Claim.referral
                  Definition

                  A reference to a referral resource.

                  ShortTreatment referral
                  Comments

                  The referral resource which lists the date, practitioner, reason and other supporting information.

                  Control0..1
                  TypeReference(ServiceRequest)
                  Is Modifierfalse
                  Summaryfalse
                  Requirements

                  Some insurers require proof of referral to pay for services or to pay specialist rates for services.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  172. Claim.facility
                  Definition

                  Facility where the services were provided.

                  ShortServicing facility
                  Control0..1
                  TypeReference(Location)
                  Is Modifierfalse
                  Summaryfalse
                  Requirements

                  Insurance adjudication can be dependant on where services were delivered.

                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  174. Claim.careTeam
                  Definition

                  Prescriber reference

                  ShortPrescriber
                  Comments

                  The careTeam represents the specific practitioner that prescribed the medication. Thus, a single careTeam element is included in the RTPBC request

                  Control1..1
                  TypeBackboneElement
                  Is Modifierfalse
                  Must Supporttrue
                  Summaryfalse
                  Requirements

                  The specific practitioner that prescribed the medication.

                  LabelPrescriber
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  176. Claim.careTeam.id
                  Definition

                  Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                  ShortUnique id for inter-element referencing
                  Control0..1
                  Typestring
                  Is Modifierfalse
                  XML FormatIn the XML format, this property is represented as an attribute.
                  Summaryfalse
                  178. Claim.careTeam.extension
                  Definition

                  May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                  ShortAdditional content defined by implementations
                  Comments

                  There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                  Control0..*
                  TypeExtension
                  Is Modifierfalse
                  Summaryfalse
                  Alternate Namesextensions, user content
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                  180. Claim.careTeam.modifierExtension
                  Definition

                  May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                  Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                  ShortExtensions that cannot be ignored even if unrecognized
                  Comments

                  There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                  Control0..*
                  TypeExtension
                  Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                  Summarytrue
                  Requirements

                  Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                  Alternate Namesextensions, user content, modifiers
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                  182. Claim.careTeam.sequence
                  Definition

                  A number to uniquely identify care team entries.

                  ShortOrder of care team
                  Control1..1
                  TypepositiveInt
                  Is Modifierfalse
                  Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                  Must Supporttrue
                  Summaryfalse
                  Requirements

                  Necessary to maintain the order of the care team and provide a mechanism to link individuals to claim details.

                  Fixed Value1
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  184. Claim.careTeam.provider
                  Definition

                  Prescriber of the item being submitted

                  ShortPrescriber
                  Control1..1
                  TypeReference(US Core Practitioner Profile)
                  Is Modifierfalse
                  Must Supporttrue
                  Summaryfalse
                  Requirements

                  Often a regulatory requirement to specify the responsible provider.

                  LabelPrescriber
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  186. Claim.careTeam.provider.id
                  Definition

                  Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                  ShortUnique id for inter-element referencing
                  Control0..1
                  Typestring
                  Is Modifierfalse
                  XML FormatIn the XML format, this property is represented as an attribute.
                  Summaryfalse
                  188. Claim.careTeam.provider.extension
                  Definition

                  May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                  ShortAdditional content defined by implementations
                  Comments

                  There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                  Control0..*
                  TypeExtension
                  Is Modifierfalse
                  Summaryfalse
                  Alternate Namesextensions, user content
                  Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                  ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                  SlicingThis element introduces a set of slices on Claim.careTeam.provider.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                  • value @ url
                  • 190. Claim.careTeam.provider.reference
                    Definition

                    Reference to a Practitioner resource that represents the prescriber

                    ShortPrescriber Reference
                    Comments

                    Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

                    Control1..1
                    This element is affected by the following invariants: ref-1
                    Typestring
                    Is Modifierfalse
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    Must Supporttrue
                    Summarytrue
                    LabelPrescriber Reference
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    192. Claim.careTeam.provider.type
                    Definition

                    The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

                    The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).

                    ShortType the reference refers to (e.g. "Patient")
                    Comments

                    This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.

                    Control0..1
                    BindingUnless not suitable, these codes SHALL be taken from ResourceType
                    (extensible to http://hl7.org/fhir/ValueSet/resource-types)

                    Aa resource (or, for logical models, the URI of the logical model).

                    Typeuri
                    Is Modifierfalse
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    Summarytrue
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    194. Claim.careTeam.provider.identifier
                    Definition

                    An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

                    ShortLogical reference, when literal reference is not known
                    Comments

                    When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

                    When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

                    Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

                    Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

                    NoteThis is a business identifier, not a resource identifier (see discussion)
                    Control0..1
                    TypeIdentifier
                    Is Modifierfalse
                    Summarytrue
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    196. Claim.careTeam.provider.display
                    Definition

                    Plain text narrative that identifies the resource in addition to the resource reference.

                    ShortText alternative for the resource
                    Comments

                    This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

                    Control0..1
                    Typestring
                    Is Modifierfalse
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    Summarytrue
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    198. Claim.careTeam.responsible
                    Definition

                    The party who is billing and/or responsible for the claimed products or services.

                    ShortIndicator of the lead practitioner
                    Comments

                    Responsible might not be required when there is only a single provider listed.

                    Control0..1
                    Typeboolean
                    Is Modifierfalse
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    Summaryfalse
                    Requirements

                    When multiple parties are present it is required to distinguish the lead or responsible individual.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    200. Claim.careTeam.role
                    Definition

                    The lead, assisting or supervising practitioner and their discipline if a multidisciplinary team.

                    ShortFunction within the team
                    Comments

                    Role might not be required when there is only a single provider listed.

                    Control0..1
                    BindingFor example codes, see ClaimCareTeamRoleCodes
                    (example to http://hl7.org/fhir/ValueSet/claim-careteamrole)

                    The role codes for the care team members.

                    TypeCodeableConcept
                    Is Modifierfalse
                    Summaryfalse
                    Requirements

                    When multiple parties are present it is required to distinguish the roles performed by each member.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    202. Claim.careTeam.qualification
                    Definition

                    The qualification of the practitioner which is applicable for this service.

                    ShortPractitioner credential or specialization
                    Control0..1
                    BindingFor example codes, see ExampleProviderQualificationCodes
                    (example to http://hl7.org/fhir/ValueSet/provider-qualification)

                    Provider professional qualifications.

                    TypeCodeableConcept
                    Is Modifierfalse
                    Summaryfalse
                    Requirements

                    Need to specify which qualification a provider is delivering the product or service under.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    204. Claim.supportingInfo
                    Definition

                    Additional information codes regarding exceptions, special considerations, the condition, situation, prior or concurrent issues.

                    ShortSupporting information
                    Comments

                    Often there are multiple jurisdiction specific valuesets which are required.

                    Control0..*
                    TypeBackboneElement
                    Is Modifierfalse
                    Summaryfalse
                    Requirements

                    Typically these information codes are required to support the services rendered or the adjudication of the services rendered.

                    Alternate NamesAttachments Exception Codes Occurrence Codes Value codes
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    206. Claim.supportingInfo.id
                    Definition

                    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                    ShortUnique id for inter-element referencing
                    Control0..1
                    Typestring
                    Is Modifierfalse
                    XML FormatIn the XML format, this property is represented as an attribute.
                    Summaryfalse
                    208. Claim.supportingInfo.extension
                    Definition

                    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                    ShortAdditional content defined by implementations
                    Comments

                    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                    Control0..*
                    TypeExtension
                    Is Modifierfalse
                    Summaryfalse
                    Alternate Namesextensions, user content
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                    210. Claim.supportingInfo.modifierExtension
                    Definition

                    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                    ShortExtensions that cannot be ignored even if unrecognized
                    Comments

                    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                    Control0..*
                    TypeExtension
                    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                    Summarytrue
                    Requirements

                    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                    Alternate Namesextensions, user content, modifiers
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                    212. Claim.supportingInfo.sequence
                    Definition

                    A number to uniquely identify supporting information entries.

                    ShortInformation instance identifier
                    Control1..1
                    TypepositiveInt
                    Is Modifierfalse
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    Summaryfalse
                    Requirements

                    Necessary to maintain the order of the supporting information items and provide a mechanism to link to claim details.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    214. Claim.supportingInfo.category
                    Definition

                    The general class of the information supplied: information; exception; accident, employment; onset, etc.

                    ShortClassification of the supplied information
                    Comments

                    This may contain a category for the local bill type codes.

                    Control1..1
                    BindingFor example codes, see ClaimInformationCategoryCodes
                    (example to http://hl7.org/fhir/ValueSet/claim-informationcategory)

                    The valuset used for additional information category codes.

                    TypeCodeableConcept
                    Is Modifierfalse
                    Summaryfalse
                    Requirements

                    Required to group or associate information items with common characteristics. For example: admission information or prior treatments.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    216. Claim.supportingInfo.code
                    Definition

                    System and code pertaining to the specific information regarding special conditions relating to the setting, treatment or patient for which care is sought.

                    ShortType of information
                    Control0..1
                    BindingFor example codes, see ExceptionCodes
                    (example to http://hl7.org/fhir/ValueSet/claim-exception)

                    The valuset used for additional information codes.

                    TypeCodeableConcept
                    Is Modifierfalse
                    Summaryfalse
                    Requirements

                    Required to identify the kind of additional information.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    218. Claim.supportingInfo.timing[x]
                    Definition

                    The date when or period to which this information refers.

                    ShortWhen it occurred
                    Control0..1
                    TypeChoice of: date, Period
                    [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
                    Is Modifierfalse
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    Summaryfalse
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    220. Claim.supportingInfo.value[x]
                    Definition

                    Additional data or information such as resources, documents, images etc. including references to the data or the actual inclusion of the data.

                    ShortData to be provided
                    Comments

                    Could be used to provide references to other resources, document. For example could contain a PDF in an Attachment of the Police Report for an Accident.

                    Control0..1
                    TypeChoice of: boolean, string, Quantity, Attachment, Reference(Resource)
                    [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
                    Is Modifierfalse
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    Summaryfalse
                    Requirements

                    To convey the data content to be provided when the information is more than a simple code or period.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    222. Claim.supportingInfo.reason
                    Definition

                    Provides the reason in the situation where a reason code is required in addition to the content.

                    ShortExplanation for the information
                    Comments

                    For example: the reason for the additional stay, or why a tooth is missing.

                    Control0..1
                    BindingFor example codes, see MissingToothReasonCodes
                    (example to http://hl7.org/fhir/ValueSet/missing-tooth-reason)

                    Reason codes for the missing teeth.

                    TypeCodeableConcept
                    Is Modifierfalse
                    Summaryfalse
                    Requirements

                    Needed when the supporting information has both a date and amount/value and requires explanation.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    224. Claim.diagnosis
                    Definition

                    Information about diagnoses relevant to the claim items.

                    ShortPertinent diagnosis information
                    Control0..*
                    TypeBackboneElement
                    Is Modifierfalse
                    Summaryfalse
                    Requirements

                    Required for the adjudication by provided context for the services and product listed.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    226. Claim.diagnosis.id
                    Definition

                    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                    ShortUnique id for inter-element referencing
                    Control0..1
                    Typestring
                    Is Modifierfalse
                    XML FormatIn the XML format, this property is represented as an attribute.
                    Summaryfalse
                    228. Claim.diagnosis.extension
                    Definition

                    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                    ShortAdditional content defined by implementations
                    Comments

                    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                    Control0..*
                    TypeExtension
                    Is Modifierfalse
                    Summaryfalse
                    Alternate Namesextensions, user content
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                    230. Claim.diagnosis.modifierExtension
                    Definition

                    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                    ShortExtensions that cannot be ignored even if unrecognized
                    Comments

                    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                    Control0..*
                    TypeExtension
                    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                    Summarytrue
                    Requirements

                    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                    Alternate Namesextensions, user content, modifiers
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                    232. Claim.diagnosis.sequence
                    Definition

                    A number to uniquely identify diagnosis entries.

                    ShortDiagnosis instance identifier
                    Comments

                    Diagnosis are presented in list order to their expected importance: primary, secondary, etc.

                    Control1..1
                    TypepositiveInt
                    Is Modifierfalse
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    Summaryfalse
                    Requirements

                    Necessary to maintain the order of the diagnosis items and provide a mechanism to link to claim details.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    234. Claim.diagnosis.diagnosis[x]
                    Definition

                    The nature of illness or problem in a coded form or as a reference to an external defined Condition.

                    ShortNature of illness or problem
                    Control1..1
                    BindingFor example codes, see ICD-10Codes
                    (example to http://hl7.org/fhir/ValueSet/icd-10)

                    Example ICD10 Diagnostic codes.

                    TypeChoice of: CodeableConcept, Reference(Condition)
                    [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
                    Is Modifierfalse
                    Summaryfalse
                    Requirements

                    Provides health context for the evaluation of the products and/or services.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    236. Claim.diagnosis.type
                    Definition

                    When the condition was observed or the relative ranking.

                    ShortTiming or nature of the diagnosis
                    Comments

                    For example: admitting, primary, secondary, discharge.

                    Control0..*
                    BindingFor example codes, see ExampleDiagnosisTypeCodes
                    (example to http://hl7.org/fhir/ValueSet/ex-diagnosistype)

                    The type of the diagnosis: admitting, principal, discharge.

                    TypeCodeableConcept
                    Is Modifierfalse
                    Summaryfalse
                    Requirements

                    Often required to capture a particular diagnosis, for example: primary or discharge.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    238. Claim.diagnosis.onAdmission
                    Definition

                    Indication of whether the diagnosis was present on admission to a facility.

                    ShortPresent on admission
                    Control0..1
                    BindingFor example codes, see ExampleDiagnosisOnAdmissionCodes
                    (example to http://hl7.org/fhir/ValueSet/ex-diagnosis-on-admission)

                    Present on admission.

                    TypeCodeableConcept
                    Is Modifierfalse
                    Summaryfalse
                    Requirements

                    Many systems need to understand for adjudication if the diagnosis was present a time of admission.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    240. Claim.diagnosis.packageCode
                    Definition

                    A package billing code or bundle code used to group products and services to a particular health condition (such as heart attack) which is based on a predetermined grouping code system.

                    ShortPackage billing code
                    Comments

                    For example DRG (Diagnosis Related Group) or a bundled billing code. A patient may have a diagnosis of a Myocardial Infarction and a DRG for HeartAttack would be assigned. The Claim item (and possible subsequent claims) would refer to the DRG for those line items that were for services related to the heart attack event.

                    Control0..1
                    BindingFor example codes, see ExampleDiagnosisRelatedGroupCodes
                    (example to http://hl7.org/fhir/ValueSet/ex-diagnosisrelatedgroup)

                    The DRG codes associated with the diagnosis.

                    TypeCodeableConcept
                    Is Modifierfalse
                    Summaryfalse
                    Requirements

                    Required to relate the current diagnosis to a package billing code that is then referenced on the individual claim items which are specific to the health condition covered by the package code.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    242. Claim.procedure
                    Definition

                    Procedures performed on the patient relevant to the billing items with the claim.

                    ShortClinical procedures performed
                    Control0..*
                    TypeBackboneElement
                    Is Modifierfalse
                    Summaryfalse
                    Requirements

                    The specific clinical invention are sometimes required to be provided to justify billing a greater than customary amount for a service.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    244. Claim.procedure.id
                    Definition

                    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                    ShortUnique id for inter-element referencing
                    Control0..1
                    Typestring
                    Is Modifierfalse
                    XML FormatIn the XML format, this property is represented as an attribute.
                    Summaryfalse
                    246. Claim.procedure.extension
                    Definition

                    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                    ShortAdditional content defined by implementations
                    Comments

                    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                    Control0..*
                    TypeExtension
                    Is Modifierfalse
                    Summaryfalse
                    Alternate Namesextensions, user content
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                    248. Claim.procedure.modifierExtension
                    Definition

                    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                    ShortExtensions that cannot be ignored even if unrecognized
                    Comments

                    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                    Control0..*
                    TypeExtension
                    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                    Summarytrue
                    Requirements

                    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                    Alternate Namesextensions, user content, modifiers
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                    250. Claim.procedure.sequence
                    Definition

                    A number to uniquely identify procedure entries.

                    ShortProcedure instance identifier
                    Control1..1
                    TypepositiveInt
                    Is Modifierfalse
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    Summaryfalse
                    Requirements

                    Necessary to provide a mechanism to link to claim details.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    252. Claim.procedure.type
                    Definition

                    When the condition was observed or the relative ranking.

                    ShortCategory of Procedure
                    Comments

                    For example: primary, secondary.

                    Control0..*
                    BindingFor example codes, see ExampleProcedureTypeCodes
                    (example to http://hl7.org/fhir/ValueSet/ex-procedure-type)

                    Example procedure type codes.

                    TypeCodeableConcept
                    Is Modifierfalse
                    Summaryfalse
                    Requirements

                    Often required to capture a particular diagnosis, for example: primary or discharge.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    254. Claim.procedure.date
                    Definition

                    Date and optionally time the procedure was performed.

                    ShortWhen the procedure was performed
                    Control0..1
                    TypedateTime
                    Is Modifierfalse
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    Summaryfalse
                    Requirements

                    Required for auditing purposes.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    256. Claim.procedure.procedure[x]
                    Definition

                    The code or reference to a Procedure resource which identifies the clinical intervention performed.

                    ShortSpecific clinical procedure
                    Control1..1
                    BindingFor example codes, see ICD-10ProcedureCodes
                    (example to http://hl7.org/fhir/ValueSet/icd-10-procedures)

                    Example ICD10 Procedure codes.

                    TypeChoice of: CodeableConcept, Reference(Procedure)
                    [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
                    Is Modifierfalse
                    Summaryfalse
                    Requirements

                    This identifies the actual clinical procedure.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    258. Claim.procedure.udi
                    Definition

                    Unique Device Identifiers associated with this line item.

                    ShortUnique device identifier
                    Control0..*
                    TypeReference(Device)
                    Is Modifierfalse
                    Summaryfalse
                    Requirements

                    The UDI code allows the insurer to obtain device level information on the product supplied.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    260. Claim.insurance
                    Definition

                    The patient's pharmacy coverage information

                    ShortPharmacy Coverage
                    Comments

                    All insurance coverages for the patient which may be applicable for reimbursement, of the products and services listed in the claim, are typically provided in the claim to allow insurers to confirm the ordering of the insurance coverages relative to local 'coordination of benefit' rules. One coverage (and only one) with 'focal=true' is to be used in the adjudication of this claim. Coverages appearing before the focal Coverage in the list, and where 'Coverage.subrogation=false', should provide a reference to the ClaimResponse containing the adjudication results of the prior claim.

                    Control1..1
                    TypeBackboneElement
                    Is Modifierfalse
                    Must Supporttrue
                    Summarytrue
                    Requirements

                    At least one insurer is required for a claim to be a claim.

                    LabelPharmacy Coverage
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    262. Claim.insurance.id
                    Definition

                    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                    ShortUnique id for inter-element referencing
                    Control0..1
                    Typestring
                    Is Modifierfalse
                    XML FormatIn the XML format, this property is represented as an attribute.
                    Summaryfalse
                    264. Claim.insurance.extension
                    Definition

                    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                    ShortAdditional content defined by implementations
                    Comments

                    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                    Control0..*
                    TypeExtension
                    Is Modifierfalse
                    Summaryfalse
                    Alternate Namesextensions, user content
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                    266. Claim.insurance.modifierExtension
                    Definition

                    May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                    Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                    ShortExtensions that cannot be ignored even if unrecognized
                    Comments

                    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                    Control0..*
                    TypeExtension
                    Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                    Summarytrue
                    Requirements

                    Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                    Alternate Namesextensions, user content, modifiers
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                    268. Claim.insurance.sequence
                    Definition

                    A number to uniquely identify insurance entries and provide a sequence of coverages to convey coordination of benefit order.

                    ShortInsurance instance identifier
                    Comments

                    Only one set of coverage is submitted in the request. Value is always '1'

                    Control1..1
                    TypepositiveInt
                    Is Modifierfalse
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    Must Supporttrue
                    Summarytrue
                    Requirements

                    To maintain order of the coverages.

                    Fixed Value1
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    270. Claim.insurance.focal
                    Definition

                    A flag to indicate that this Coverage is to be used for adjudication of this claim when set to true.

                    ShortCoverage to be used for adjudication
                    Comments

                    A patient may (will) have multiple insurance policies which provide reimbursement for healthcare services and products. For example a person may also be covered by their spouse's policy and both appear in the list (and may be from the same insurer). This flag will be set to true for only one of the listed policies and that policy will be used for adjudicating this claim. Other claims would be created to request adjudication against the other listed policies.

                    Control1..1
                    Typeboolean
                    Is Modifierfalse
                    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                    Must Supporttrue
                    Summarytrue
                    Requirements

                    To identify which coverage in the list is being used to adjudicate this claim.

                    Fixed Valuetrue
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    272. Claim.insurance.identifier
                    Definition

                    The business identifier to be used when the claim is sent for adjudication against this insurance policy.

                    ShortPre-assigned Claim number
                    Comments

                    Only required in jurisdictions where insurers, rather than the provider, are required to send claims to insurers that appear after them in the list. This element is not required when 'subrogation=true'.

                    NoteThis is a business identifier, not a resource identifier (see discussion)
                    Control0..1
                    TypeIdentifier
                    Is Modifierfalse
                    Summaryfalse
                    Requirements

                    This will be the claim number should it be necessary to create this claim in the future. This is provided so that payors may forward claims to other payors in the Coordination of Benefit for adjudication rather than the provider being required to initiate each adjudication.

                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    274. Claim.insurance.coverage
                    Definition

                    Reference to a Coverage resource containing identification of the patient's pharmacy coverage

                    ShortPharmacy Coverage Reference
                    Control1..1
                    TypeReference(RTPBC Coverage)
                    Is Modifierfalse
                    Must Supporttrue
                    Summarytrue
                    Requirements

                    Required to allow the adjudicator to locate the correct policy and history within their information system.

                    LabelPharmacy Coverage Reference
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    276. Claim.insurance.coverage.id
                    Definition

                    Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                    ShortUnique id for inter-element referencing
                    Control0..1
                    Typestring
                    Is Modifierfalse
                    XML FormatIn the XML format, this property is represented as an attribute.
                    Summaryfalse
                    278. Claim.insurance.coverage.extension
                    Definition

                    May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                    ShortAdditional content defined by implementations
                    Comments

                    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                    Control0..*
                    TypeExtension
                    Is Modifierfalse
                    Summaryfalse
                    Alternate Namesextensions, user content
                    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                    SlicingThis element introduces a set of slices on Claim.insurance.coverage.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                    • value @ url
                    • 280. Claim.insurance.coverage.reference
                      Definition

                      Reference to a Coverage resource containing identification of the patient's pharmacy coverage

                      ShortPharmacy Coverage Reference
                      Comments

                      Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

                      Control0..1
                      This element is affected by the following invariants: ref-1
                      Typestring
                      Is Modifierfalse
                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                      Must Supporttrue
                      Summarytrue
                      LabelPharmacy Coverage Reference
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      282. Claim.insurance.coverage.type
                      Definition

                      The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

                      The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).

                      ShortType the reference refers to (e.g. "Patient")
                      Comments

                      This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.

                      Control0..1
                      BindingUnless not suitable, these codes SHALL be taken from ResourceType
                      (extensible to http://hl7.org/fhir/ValueSet/resource-types)

                      Aa resource (or, for logical models, the URI of the logical model).

                      Typeuri
                      Is Modifierfalse
                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                      Summarytrue
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      284. Claim.insurance.coverage.identifier
                      Definition

                      An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

                      ShortLogical reference, when literal reference is not known
                      Comments

                      When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

                      When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

                      Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

                      Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

                      NoteThis is a business identifier, not a resource identifier (see discussion)
                      Control0..1
                      TypeIdentifier
                      Is Modifierfalse
                      Summarytrue
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      286. Claim.insurance.coverage.display
                      Definition

                      Plain text narrative that identifies the resource in addition to the resource reference.

                      ShortText alternative for the resource
                      Comments

                      This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

                      Control0..1
                      Typestring
                      Is Modifierfalse
                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                      Summarytrue
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      288. Claim.insurance.businessArrangement
                      Definition

                      A business agreement number established between the provider and the insurer for special business processing purposes.

                      ShortAdditional provider contract number
                      Control0..1
                      Typestring
                      Is Modifierfalse
                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                      Summaryfalse
                      Requirements

                      Providers may have multiple business arrangements with a given insurer and must supply the specific contract number for adjudication.

                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      290. Claim.insurance.preAuthRef
                      Definition

                      Reference numbers previously provided by the insurer to the provider to be quoted on subsequent claims containing services or products related to the prior authorization.

                      ShortPrior authorization reference number
                      Comments

                      This value is an alphanumeric string that may be provided over the phone, via text, via paper, or within a ClaimResponse resource and is not a FHIR Identifier.

                      Control0..*
                      Typestring
                      Is Modifierfalse
                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                      Summaryfalse
                      Requirements

                      Providers must quote previously issued authorization reference numbers in order to obtain adjudication as previously advised on the Preauthorization.

                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      292. Claim.insurance.claimResponse
                      Definition

                      The result of the adjudication of the line items for the Coverage specified in this insurance.

                      ShortAdjudication results
                      Comments

                      Must not be specified when 'focal=true' for this insurance.

                      Control0..1
                      TypeReference(ClaimResponse)
                      Is Modifierfalse
                      Summaryfalse
                      Requirements

                      An insurer need the adjudication results from prior insurers to determine the outstanding balance remaining by item for the items in the curent claim.

                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      294. Claim.accident
                      Definition

                      Details of an accident which resulted in injuries which required the products and services listed in the claim.

                      ShortDetails of the event
                      Control0..1
                      TypeBackboneElement
                      Is Modifierfalse
                      Summaryfalse
                      Requirements

                      When healthcare products and services are accident related, benefits may be payable under accident provisions of policies, such as automotive, etc before they are payable under normal health insurance.

                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      296. Claim.accident.id
                      Definition

                      Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                      ShortUnique id for inter-element referencing
                      Control0..1
                      Typestring
                      Is Modifierfalse
                      XML FormatIn the XML format, this property is represented as an attribute.
                      Summaryfalse
                      298. Claim.accident.extension
                      Definition

                      May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                      ShortAdditional content defined by implementations
                      Comments

                      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                      Control0..*
                      TypeExtension
                      Is Modifierfalse
                      Summaryfalse
                      Alternate Namesextensions, user content
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                      300. Claim.accident.modifierExtension
                      Definition

                      May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                      Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                      ShortExtensions that cannot be ignored even if unrecognized
                      Comments

                      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                      Control0..*
                      TypeExtension
                      Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                      Summarytrue
                      Requirements

                      Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                      Alternate Namesextensions, user content, modifiers
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                      302. Claim.accident.date
                      Definition

                      Date of an accident event related to the products and services contained in the claim.

                      ShortWhen the incident occurred
                      Comments

                      The date of the accident has to precede the dates of the products and services but within a reasonable timeframe.

                      Control1..1
                      Typedate
                      Is Modifierfalse
                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                      Summaryfalse
                      Requirements

                      Required for audit purposes and adjudication.

                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      304. Claim.accident.type
                      Definition

                      The type or context of the accident event for the purposes of selection of potential insurance coverages and determination of coordination between insurers.

                      ShortThe nature of the accident
                      Control0..1
                      BindingUnless not suitable, these codes SHALL be taken from ActIncidentCode
                      (extensible to http://terminology.hl7.org/ValueSet/v3-ActIncidentCode)

                      Type of accident: work place, auto, etc.

                      TypeCodeableConcept
                      Is Modifierfalse
                      Summaryfalse
                      Requirements

                      Coverage may be dependant on the type of accident.

                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      306. Claim.accident.location[x]
                      Definition

                      The physical location of the accident event.

                      ShortWhere the event occurred
                      Control0..1
                      TypeChoice of: Address, Reference(Location)
                      [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
                      Is Modifierfalse
                      Summaryfalse
                      Requirements

                      Required for audit purposes and determination of applicable insurance liability.

                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      308. Claim.item
                      Definition

                      A claim line. Either a simple product or service or a 'group' of details which can each be a simple items or groups of sub-details.

                      ShortMax 1 item per request
                      Control1..1
                      TypeBackboneElement
                      Is Modifierfalse
                      Must Supporttrue
                      Summaryfalse
                      Requirements

                      The items to be processed for adjudication.

                      LabelMax 1 item per request
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      310. Claim.item.id
                      Definition

                      Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                      ShortUnique id for inter-element referencing
                      Control0..1
                      Typestring
                      Is Modifierfalse
                      XML FormatIn the XML format, this property is represented as an attribute.
                      Summaryfalse
                      312. Claim.item.extension
                      Definition

                      May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                      ShortAdditional content defined by implementations
                      Comments

                      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                      Control0..*
                      TypeExtension
                      Is Modifierfalse
                      Summaryfalse
                      Alternate Namesextensions, user content
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                      314. Claim.item.modifierExtension
                      Definition

                      May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                      Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                      ShortExtensions that cannot be ignored even if unrecognized
                      Comments

                      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                      Control0..*
                      TypeExtension
                      Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                      Summarytrue
                      Requirements

                      Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                      Alternate Namesextensions, user content, modifiers
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                      316. Claim.item.sequence
                      Definition

                      A number to uniquely identify item entries.

                      ShortItem instance identifier
                      Comments

                      A maximum of one product is submitted per request. Value is always '1'

                      Control1..1
                      TypepositiveInt
                      Is Modifierfalse
                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                      Must Supporttrue
                      Summaryfalse
                      Requirements

                      Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.

                      Fixed Value1
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      318. Claim.item.careTeamSequence
                      Definition

                      A reference to the Care Team composite in this resource that reflects the prescriber

                      ShortCare Team Sequence ID Reference
                      Comments

                      Populate with a reference to .careTeam.sequence.@id

                      Control1..1
                      TypepositiveInt
                      Is Modifierfalse
                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                      Must Supporttrue
                      Summaryfalse
                      Requirements

                      Need to identify the individuals and their roles in the provision of the product or service.

                      LabelCare Team Sequence ID Reference
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      320. Claim.item.diagnosisSequence
                      Definition

                      Diagnosis applicable for this service or product.

                      ShortApplicable diagnoses
                      Control0..*
                      TypepositiveInt
                      Is Modifierfalse
                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                      Summaryfalse
                      Requirements

                      Need to related the product or service to the associated diagnoses.

                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      322. Claim.item.procedureSequence
                      Definition

                      Procedures applicable for this service or product.

                      ShortApplicable procedures
                      Control0..*
                      TypepositiveInt
                      Is Modifierfalse
                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                      Summaryfalse
                      Requirements

                      Need to provide any listed specific procedures to support the product or service being claimed.

                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      324. Claim.item.informationSequence
                      Definition

                      Exceptions, special conditions and supporting information applicable for this service or product.

                      ShortApplicable exception and supporting information
                      Control0..*
                      TypepositiveInt
                      Is Modifierfalse
                      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                      Summaryfalse
                      Requirements

                      Need to reference the supporting information items that relate directly to this product or service.

                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      326. Claim.item.revenue
                      Definition

                      The type of revenue or cost center providing the product and/or service.

                      ShortRevenue or cost center code
                      Control0..1
                      BindingFor example codes, see ExampleRevenueCenterCodes
                      (example to http://hl7.org/fhir/ValueSet/ex-revenue-center)

                      Codes for the revenue or cost centers supplying the service and/or products.

                      TypeCodeableConcept
                      Is Modifierfalse
                      Summaryfalse
                      Requirements

                      Needed in the processing of institutional claims.

                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      328. Claim.item.category
                      Definition

                      Code to identify the general type of benefits under which products and services are provided.

                      ShortBenefit classification
                      Comments

                      Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

                      Control0..1
                      BindingFor example codes, see BenefitCategoryCodes
                      (example to http://hl7.org/fhir/ValueSet/ex-benefitcategory)

                      Benefit categories such as: oral-basic, major, glasses.

                      TypeCodeableConcept
                      Is Modifierfalse
                      Summaryfalse
                      Requirements

                      Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      330. Claim.item.productOrService
                      Definition

                      A product identifier for the prescribed medication. Either an NDC11 or an RxNorm code for a prescribable product (representing drug name, strength and dose form)

                      ShortPrescribed Product
                      Comments

                      The NDC11 is an 11-digit normalized format consisting of a 5-digit labeler segment, 4-digit product segment, and 2-digit package segment, with no dashes

                      Control1..1
                      BindingUnless not suitable, these codes SHALL be taken from RTPBC Prescribable Product Code Value Set
                      (extensible to http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-prescribable-product-code)

                      RTPBC prescribable product codes (NDC11 and RxNorm)

                      TypeCodeableConcept
                      Is Modifierfalse
                      Must Supporttrue
                      Summaryfalse
                      Requirements

                      Necessary to state what was provided or done.

                      LabelPrescribed Product
                      Alternate NamesDrug Code, Bill Code, Service Code
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      332. Claim.item.productOrService.id
                      Definition

                      Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                      ShortUnique id for inter-element referencing
                      Control0..1
                      Typestring
                      Is Modifierfalse
                      XML FormatIn the XML format, this property is represented as an attribute.
                      Summaryfalse
                      334. Claim.item.productOrService.extension
                      Definition

                      May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                      ShortAdditional content defined by implementations
                      Comments

                      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                      Control0..*
                      TypeExtension
                      Is Modifierfalse
                      Summaryfalse
                      Alternate Namesextensions, user content
                      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                      SlicingThis element introduces a set of slices on Claim.item.productOrService.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                      • value @ url
                      • 336. Claim.item.productOrService.coding
                        Definition

                        A reference to a code defined by a terminology system.

                        ShortCode defined by a terminology system
                        Comments

                        Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

                        Control1..*
                        TypeCoding
                        Is Modifierfalse
                        Must Supporttrue
                        Summarytrue
                        Requirements

                        Allows for alternative encodings within a code system, and translations to other code systems.

                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                        338. Claim.item.productOrService.coding.id
                        Definition

                        Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                        ShortUnique id for inter-element referencing
                        Control0..1
                        Typestring
                        Is Modifierfalse
                        XML FormatIn the XML format, this property is represented as an attribute.
                        Summaryfalse
                        340. Claim.item.productOrService.coding.extension
                        Definition

                        May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                        ShortAdditional content defined by implementations
                        Comments

                        There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                        Control0..*
                        TypeExtension
                        Is Modifierfalse
                        Summaryfalse
                        Alternate Namesextensions, user content
                        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                        SlicingThis element introduces a set of slices on Claim.item.productOrService.coding.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                        • value @ url
                        • 342. Claim.item.productOrService.coding.system
                          Definition

                          The identification of the code system that defines the meaning of the symbol in the code.

                          ShortIdentity of the terminology system
                          Comments

                          The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

                          Control1..1
                          Typeuri
                          Is Modifierfalse
                          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                          Must Supporttrue
                          Summarytrue
                          Requirements

                          Need to be unambiguous about the source of the definition of the symbol.

                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          344. Claim.item.productOrService.coding.version
                          Definition

                          The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

                          ShortVersion of the system - if relevant
                          Comments

                          Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

                          NoteThis is a business version Id, not a resource version Id (see discussion)
                          Control0..1
                          Typestring
                          Is Modifierfalse
                          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                          Summarytrue
                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          346. Claim.item.productOrService.coding.code
                          Definition

                          A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

                          ShortSymbol in syntax defined by the system
                          Control1..1
                          Typecode
                          Is Modifierfalse
                          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                          Must Supporttrue
                          Summarytrue
                          Requirements

                          Need to refer to a particular code in the system.

                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          348. Claim.item.productOrService.coding.display
                          Definition

                          The full prescribable product name, including drug name, strength and dose form. The drug name equals the brand name if the branded product is desired

                          ShortProduct Description
                          Control1..1
                          Typestring
                          Is Modifierfalse
                          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                          Must Supporttrue
                          Summarytrue
                          Requirements

                          Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

                          LabelProduct Description
                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          350. Claim.item.productOrService.coding.userSelected
                          Definition

                          Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).

                          ShortIf this coding was chosen directly by the user
                          Comments

                          Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

                          Control0..1
                          Typeboolean
                          Is Modifierfalse
                          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                          Summarytrue
                          Requirements

                          This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          352. Claim.item.productOrService.text
                          Definition

                          A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

                          ShortPlain text representation of the concept
                          Comments

                          Very often the text is the same as a displayName of one of the codings.

                          Control0..1
                          Typestring
                          Is Modifierfalse
                          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                          Summarytrue
                          Requirements

                          The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          354. Claim.item.modifier
                          Definition

                          Item typification or modifiers codes to convey additional context for the product or service.

                          ShortProduct or service billing modifiers
                          Comments

                          For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or outside of office hours.

                          Control0..*
                          BindingFor example codes, see ModifierTypeCodes
                          (example to http://hl7.org/fhir/ValueSet/claim-modifiers)

                          Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

                          TypeCodeableConcept
                          Is Modifierfalse
                          Summaryfalse
                          Requirements

                          To support inclusion of the item for adjudication or to charge an elevated fee.

                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          356. Claim.item.programCode
                          Definition

                          Identifies the program under which this may be recovered.

                          ShortProgram the product or service is provided under
                          Comments

                          For example: Neonatal program, child dental program or drug users recovery program.

                          Control0..*
                          BindingFor example codes, see ExampleProgramReasonCodes
                          (example to http://hl7.org/fhir/ValueSet/ex-program-code)

                          Program specific reason codes.

                          TypeCodeableConcept
                          Is Modifierfalse
                          Summaryfalse
                          Requirements

                          Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          358. Claim.item.serviced[x]
                          Definition

                          The date or dates when the service or product was supplied, performed or completed.

                          ShortDate or dates of service or product delivery
                          Control0..1
                          TypeChoice of: date, Period
                          [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
                          Is Modifierfalse
                          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                          Summaryfalse
                          Requirements

                          Needed to determine whether the service or product was provided during the term of the insurance coverage.

                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          360. Claim.item.location[x]
                          Definition

                          Where the product or service was provided.

                          ShortPlace of service or where product was supplied
                          Control0..1
                          BindingFor example codes, see ExampleServicePlaceCodes
                          (example to http://hl7.org/fhir/ValueSet/service-place)

                          Place of service: pharmacy, school, prison, etc.

                          TypeChoice of: CodeableConcept, Address, Reference(Location)
                          [x] NoteSeeChoice of Data Typesfor further information about how to use [x]
                          Is Modifierfalse
                          Summaryfalse
                          Requirements

                          The location can alter whether the item was acceptable for insurance purposes or impact the determination of the benefit amount.

                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          362. Claim.item.quantity
                          Definition

                          The number of repetitions of a service or product.

                          ShortPrescribed Quantity
                          Control1..1
                          TypeQuantity(SimpleQuantity)
                          Is Modifierfalse
                          Must Supporttrue
                          Summaryfalse
                          Requirements

                          Required when the product or service code does not convey the quantity provided.

                          LabelPrescribed Quantity
                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          364. Claim.item.quantity.id
                          Definition

                          Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                          ShortUnique id for inter-element referencing
                          Control0..1
                          Typestring
                          Is Modifierfalse
                          XML FormatIn the XML format, this property is represented as an attribute.
                          Summaryfalse
                          366. Claim.item.quantity.extension
                          Definition

                          May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                          ShortAdditional content defined by implementations
                          Comments

                          There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                          Control0..*
                          TypeExtension
                          Is Modifierfalse
                          Summaryfalse
                          Alternate Namesextensions, user content
                          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                          SlicingThis element introduces a set of slices on Claim.item.quantity.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
                          • value @ url
                          • 368. Claim.item.quantity.value
                            Definition

                            The prescribed quantity in terms of the applicable billing unit of measure

                            ShortQuantity in Billing Units
                            Comments

                            The implicit precision in the value should always be honored. Monetary values have their own rules for handling precision (refer to standard accounting text books).

                            Control1..1
                            Typedecimal
                            Is Modifierfalse
                            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                            Must Supporttrue
                            Summarytrue
                            Requirements

                            Precision is handled implicitly in almost all cases of measurement.

                            LabelQuantity in Billing Units
                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            370. Claim.item.quantity.comparator
                            Definition

                            Not allowed to be used in this context

                            Short< | <= | >= | > - how to understand the value
                            Control0..0
                            BindingThe codes SHALL be taken from QuantityComparator
                            (required to http://hl7.org/fhir/ValueSet/quantity-comparator|4.0.1)

                            How the Quantity should be understood and represented.

                            Typecode
                            Is Modifiertrue because This is labeled as "Is Modifier" because the comparator modifies the interpretation of the value significantly. If there is no comparator, then there is no modification of the value
                            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                            Summarytrue
                            Requirements

                            Need a framework for handling measures where the value is <5ug/L or >400mg/L due to the limitations of measuring methodology.

                            Meaning if MissingIf there is no comparator, then there is no modification of the value
                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            372. Claim.item.quantity.unit
                            Definition

                            Pharmacy metric billing unit: GM (gram), ML (milliliter) or EA (each)

                            ShortBilling unit of measure
                            Control1..1
                            BindingUnless not suitable, these codes SHALL be taken from RTPBC Billing Unit Value Set
                            (extensible to http://hl7.org/fhir/us/carin-rtpbc/ValueSet/rtpbc-billing-unit)

                            Billing quantity unit of measure

                            Typestring
                            Is Modifierfalse
                            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                            Must Supporttrue
                            Summarytrue
                            Requirements

                            There are many representations for units of measure and in many contexts, particular representations are fixed and required. I.e. mcg for micrograms.

                            LabelBilling unit of measure
                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            374. Claim.item.quantity.system
                            Definition

                            The identification of the system that provides the coded form of the unit.

                            ShortSystem that defines coded unit form
                            Control0..1
                            This element is affected by the following invariants: qty-3
                            Typeuri
                            Is Modifierfalse
                            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                            Summarytrue
                            Requirements

                            Need to know the system that defines the coded form of the unit.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            376. Claim.item.quantity.code
                            Definition

                            A computer processable form of the unit in some unit representation system.

                            ShortCoded form of the unit
                            Comments

                            The preferred system is UCUM, but SNOMED CT can also be used (for customary units) or ISO 4217 for currency. The context of use may additionally require a code from a particular system.

                            Control0..1
                            Typecode
                            Is Modifierfalse
                            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                            Summarytrue
                            Requirements

                            Need a computable form of the unit that is fixed across all forms. UCUM provides this for quantities, but SNOMED CT provides many units of interest.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            378. Claim.item.unitPrice
                            Definition

                            If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

                            ShortFee, charge or cost per item
                            Control0..1
                            TypeMoney
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            The amount charged to the patient by the provider for a single unit.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            380. Claim.item.factor
                            Definition

                            A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

                            ShortPrice scaling factor
                            Comments

                            To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

                            Control0..1
                            Typedecimal
                            Is Modifierfalse
                            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                            Summaryfalse
                            Requirements

                            When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            382. Claim.item.net
                            Definition

                            The quantity times the unit price for an additional service or product or charge.

                            ShortTotal item cost
                            Comments

                            For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

                            Control0..1
                            TypeMoney
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            Provides the total amount claimed for the group (if a grouper) or the line item.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            384. Claim.item.udi
                            Definition

                            Unique Device Identifiers associated with this line item.

                            ShortUnique device identifier
                            Control0..*
                            TypeReference(Device)
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            The UDI code allows the insurer to obtain device level information on the product supplied.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            386. Claim.item.bodySite
                            Definition

                            Physical service site on the patient (limb, tooth, etc.).

                            ShortAnatomical location
                            Comments

                            For example: Providing a tooth code, allows an insurer to identify a provider performing a filling on a tooth that was previously removed.

                            Control0..1
                            BindingFor example codes, see OralSiteCodes
                            (example to http://hl7.org/fhir/ValueSet/tooth)

                            The code for the teeth, quadrant, sextant and arch.

                            TypeCodeableConcept
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            Allows insurer to validate specific procedures.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            388. Claim.item.subSite
                            Definition

                            A region or surface of the bodySite, e.g. limb region or tooth surface(s).

                            ShortAnatomical sub-location
                            Control0..*
                            BindingFor example codes, see SurfaceCodes
                            (example to http://hl7.org/fhir/ValueSet/surface)

                            The code for the tooth surface and surface combinations.

                            TypeCodeableConcept
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            Allows insurer to validate specific procedures.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            390. Claim.item.encounter
                            Definition

                            The Encounters during which this Claim was created or to which the creation of this record is tightly associated.

                            ShortEncounters related to this billed item
                            Comments

                            This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter.

                            Control0..*
                            TypeReference(Encounter)
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            Used in some jurisdictions to link clinical events to claim items.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            392. Claim.item.detail
                            Definition

                            A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

                            ShortProduct or service provided
                            Control0..*
                            TypeBackboneElement
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            The items to be processed for adjudication.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            394. Claim.item.detail.id
                            Definition

                            Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                            ShortUnique id for inter-element referencing
                            Control0..1
                            Typestring
                            Is Modifierfalse
                            XML FormatIn the XML format, this property is represented as an attribute.
                            Summaryfalse
                            396. Claim.item.detail.extension
                            Definition

                            May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                            ShortAdditional content defined by implementations
                            Comments

                            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                            Control0..*
                            TypeExtension
                            Is Modifierfalse
                            Summaryfalse
                            Alternate Namesextensions, user content
                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                            398. Claim.item.detail.modifierExtension
                            Definition

                            May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                            Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                            ShortExtensions that cannot be ignored even if unrecognized
                            Comments

                            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                            Control0..*
                            TypeExtension
                            Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                            Summarytrue
                            Requirements

                            Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                            Alternate Namesextensions, user content, modifiers
                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                            400. Claim.item.detail.sequence
                            Definition

                            A number to uniquely identify item entries.

                            ShortItem instance identifier
                            Control1..1
                            TypepositiveInt
                            Is Modifierfalse
                            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                            Summaryfalse
                            Requirements

                            Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            402. Claim.item.detail.revenue
                            Definition

                            The type of revenue or cost center providing the product and/or service.

                            ShortRevenue or cost center code
                            Control0..1
                            BindingFor example codes, see ExampleRevenueCenterCodes
                            (example to http://hl7.org/fhir/ValueSet/ex-revenue-center)

                            Codes for the revenue or cost centers supplying the service and/or products.

                            TypeCodeableConcept
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            Needed in the processing of institutional claims.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            404. Claim.item.detail.category
                            Definition

                            Code to identify the general type of benefits under which products and services are provided.

                            ShortBenefit classification
                            Comments

                            Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

                            Control0..1
                            BindingFor example codes, see BenefitCategoryCodes
                            (example to http://hl7.org/fhir/ValueSet/ex-benefitcategory)

                            Benefit categories such as: oral-basic, major, glasses.

                            TypeCodeableConcept
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            406. Claim.item.detail.productOrService
                            Definition

                            When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

                            ShortBilling, service, product, or drug code
                            Comments

                            If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

                            Control1..1
                            BindingFor example codes, see USCLSCodes
                            (example to http://hl7.org/fhir/ValueSet/service-uscls)

                            Allowable service and product codes.

                            TypeCodeableConcept
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            Necessary to state what was provided or done.

                            Alternate NamesDrug Code, Bill Code, Service Code
                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            408. Claim.item.detail.modifier
                            Definition

                            Item typification or modifiers codes to convey additional context for the product or service.

                            ShortService/Product billing modifiers
                            Comments

                            For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

                            Control0..*
                            BindingFor example codes, see ModifierTypeCodes
                            (example to http://hl7.org/fhir/ValueSet/claim-modifiers)

                            Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

                            TypeCodeableConcept
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            To support inclusion of the item for adjudication or to charge an elevated fee.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            410. Claim.item.detail.programCode
                            Definition

                            Identifies the program under which this may be recovered.

                            ShortProgram the product or service is provided under
                            Comments

                            For example: Neonatal program, child dental program or drug users recovery program.

                            Control0..*
                            BindingFor example codes, see ExampleProgramReasonCodes
                            (example to http://hl7.org/fhir/ValueSet/ex-program-code)

                            Program specific reason codes.

                            TypeCodeableConcept
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            412. Claim.item.detail.quantity
                            Definition

                            The number of repetitions of a service or product.

                            ShortCount of products or services
                            Control0..1
                            TypeQuantity(SimpleQuantity)
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            Required when the product or service code does not convey the quantity provided.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            414. Claim.item.detail.unitPrice
                            Definition

                            If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

                            ShortFee, charge or cost per item
                            Control0..1
                            TypeMoney
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            The amount charged to the patient by the provider for a single unit.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            416. Claim.item.detail.factor
                            Definition

                            A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

                            ShortPrice scaling factor
                            Comments

                            To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

                            Control0..1
                            Typedecimal
                            Is Modifierfalse
                            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                            Summaryfalse
                            Requirements

                            When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            418. Claim.item.detail.net
                            Definition

                            The quantity times the unit price for an additional service or product or charge.

                            ShortTotal item cost
                            Comments

                            For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

                            Control0..1
                            TypeMoney
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            Provides the total amount claimed for the group (if a grouper) or the line item.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            420. Claim.item.detail.udi
                            Definition

                            Unique Device Identifiers associated with this line item.

                            ShortUnique device identifier
                            Control0..*
                            TypeReference(Device)
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            The UDI code allows the insurer to obtain device level information on the product supplied.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            422. Claim.item.detail.subDetail
                            Definition

                            A claim detail line. Either a simple (a product or service) or a 'group' of sub-details which are simple items.

                            ShortProduct or service provided
                            Control0..*
                            TypeBackboneElement
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            The items to be processed for adjudication.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            424. Claim.item.detail.subDetail.id
                            Definition

                            Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

                            ShortUnique id for inter-element referencing
                            Control0..1
                            Typestring
                            Is Modifierfalse
                            XML FormatIn the XML format, this property is represented as an attribute.
                            Summaryfalse
                            426. Claim.item.detail.subDetail.extension
                            Definition

                            May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

                            ShortAdditional content defined by implementations
                            Comments

                            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                            Control0..*
                            TypeExtension
                            Is Modifierfalse
                            Summaryfalse
                            Alternate Namesextensions, user content
                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                            428. Claim.item.detail.subDetail.modifierExtension
                            Definition

                            May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

                            Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

                            ShortExtensions that cannot be ignored even if unrecognized
                            Comments

                            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

                            Control0..*
                            TypeExtension
                            Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
                            Summarytrue
                            Requirements

                            Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

                            Alternate Namesextensions, user content, modifiers
                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
                            430. Claim.item.detail.subDetail.sequence
                            Definition

                            A number to uniquely identify item entries.

                            ShortItem instance identifier
                            Control1..1
                            TypepositiveInt
                            Is Modifierfalse
                            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                            Summaryfalse
                            Requirements

                            Necessary to provide a mechanism to link to items from within the claim and within the adjudication details of the ClaimResponse.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            432. Claim.item.detail.subDetail.revenue
                            Definition

                            The type of revenue or cost center providing the product and/or service.

                            ShortRevenue or cost center code
                            Control0..1
                            BindingFor example codes, see ExampleRevenueCenterCodes
                            (example to http://hl7.org/fhir/ValueSet/ex-revenue-center)

                            Codes for the revenue or cost centers supplying the service and/or products.

                            TypeCodeableConcept
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            Needed in the processing of institutional claims.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            434. Claim.item.detail.subDetail.category
                            Definition

                            Code to identify the general type of benefits under which products and services are provided.

                            ShortBenefit classification
                            Comments

                            Examples include Medical Care, Periodontics, Renal Dialysis, Vision Coverage.

                            Control0..1
                            BindingFor example codes, see BenefitCategoryCodes
                            (example to http://hl7.org/fhir/ValueSet/ex-benefitcategory)

                            Benefit categories such as: oral-basic, major, glasses.

                            TypeCodeableConcept
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            Needed in the processing of institutional claims as this allows the insurer to determine whether a facial X-Ray is for dental, orthopedic, or facial surgery purposes.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            436. Claim.item.detail.subDetail.productOrService
                            Definition

                            When the value is a group code then this item collects a set of related claim details, otherwise this contains the product, service, drug or other billing code for the item.

                            ShortBilling, service, product, or drug code
                            Comments

                            If this is an actual service or product line, i.e. not a Group, then use code to indicate the Professional Service or Product supplied (e.g. CTP, HCPCS, USCLS, ICD10, NCPDP, DIN, RxNorm, ACHI, CCI). If a grouping item then use a group code to indicate the type of thing being grouped e.g. 'glasses' or 'compound'.

                            Control1..1
                            BindingFor example codes, see USCLSCodes
                            (example to http://hl7.org/fhir/ValueSet/service-uscls)

                            Allowable service and product codes.

                            TypeCodeableConcept
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            Necessary to state what was provided or done.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            438. Claim.item.detail.subDetail.modifier
                            Definition

                            Item typification or modifiers codes to convey additional context for the product or service.

                            ShortService/Product billing modifiers
                            Comments

                            For example in Oral whether the treatment is cosmetic or associated with TMJ, or for Medical whether the treatment was outside the clinic or out of office hours.

                            Control0..*
                            BindingFor example codes, see ModifierTypeCodes
                            (example to http://hl7.org/fhir/ValueSet/claim-modifiers)

                            Item type or modifiers codes, eg for Oral whether the treatment is cosmetic or associated with TMJ, or an appliance was lost or stolen.

                            TypeCodeableConcept
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            To support inclusion of the item for adjudication or to charge an elevated fee.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            440. Claim.item.detail.subDetail.programCode
                            Definition

                            Identifies the program under which this may be recovered.

                            ShortProgram the product or service is provided under
                            Comments

                            For example: Neonatal program, child dental program or drug users recovery program.

                            Control0..*
                            BindingFor example codes, see ExampleProgramReasonCodes
                            (example to http://hl7.org/fhir/ValueSet/ex-program-code)

                            Program specific reason codes.

                            TypeCodeableConcept
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            Commonly used in in the identification of publicly provided program focused on population segments or disease classifications.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            442. Claim.item.detail.subDetail.quantity
                            Definition

                            The number of repetitions of a service or product.

                            ShortCount of products or services
                            Control0..1
                            TypeQuantity(SimpleQuantity)
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            Required when the product or service code does not convey the quantity provided.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            444. Claim.item.detail.subDetail.unitPrice
                            Definition

                            If the item is not a group then this is the fee for the product or service, otherwise this is the total of the fees for the details of the group.

                            ShortFee, charge or cost per item
                            Control0..1
                            TypeMoney
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            The amount charged to the patient by the provider for a single unit.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            446. Claim.item.detail.subDetail.factor
                            Definition

                            A real number that represents a multiplier used in determining the overall value of services delivered and/or goods received. The concept of a Factor allows for a discount or surcharge multiplier to be applied to a monetary amount.

                            ShortPrice scaling factor
                            Comments

                            To show a 10% senior's discount, the value entered is: 0.90 (1.00 - 0.10).

                            Control0..1
                            Typedecimal
                            Is Modifierfalse
                            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
                            Summaryfalse
                            Requirements

                            When discounts are provided to a patient (example: Senior's discount) then this must be documented for adjudication.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            448. Claim.item.detail.subDetail.net
                            Definition

                            The quantity times the unit price for an additional service or product or charge.

                            ShortTotal item cost
                            Comments

                            For example, the formula: quantity * unitPrice * factor = net. Quantity and factor are assumed to be 1 if not supplied.

                            Control0..1
                            TypeMoney
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            Provides the total amount claimed for the group (if a grouper) or the line item.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            450. Claim.item.detail.subDetail.udi
                            Definition

                            Unique Device Identifiers associated with this line item.

                            ShortUnique device identifier
                            Control0..*
                            TypeReference(Device)
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            The UDI code allows the insurer to obtain device level information on the product supplied.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
                            452. Claim.total
                            Definition

                            The total value of the all the items in the claim.

                            ShortTotal claim cost
                            Control0..1
                            TypeMoney
                            Is Modifierfalse
                            Summaryfalse
                            Requirements

                            Used for control total purposes.

                            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))